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

Expected 8-Week Prenatal vs 12-Week Perinatal Tenofovir Alafenamide Prophylaxis to Prevent Mother-to-Child Transmission of Hepatitis B Virus: A Multicenter, Prospective, Open-Label, Randomized Controlled Trial

INTRODUCTION

The course of maternal antiviral prophylaxis to prevent mother-to-child transmission of hepatitis B virus (HBV-MTCT) varies greatly, and it has not been demonstrated in a randomized controlled study.

METHODS

In this multicenter, open-label, randomized controlled trial, eligible pregnant women with HBV DNA of 5.3-9.0 log 10 IU/mL who received tenofovir alafenamide fumarate (TAF) from the first day of 33 gestational weeks to delivery (expected 8 week) or to 4 weeks postpartum (expected 12 week) were randomly enrolled at a 1:1 ratio and followed until 6 months postpartum. All infants received standard immunoprophylaxis (hepatitis B immunoglobulin and vaccine). The primary end point was the safety of mothers and infants. The secondary end point was the HBV-MTCT rate of infants at the age of 7 months.

RESULTS

Among 119 and 120 intention-to-treat pregnant women, 115 and 116 women were followed until delivery, and 110 and 112 per-protocol mother-infant dyads in 2 groups completed the study. Overall, TAF was well tolerated, no one discontinued the therapy due to adverse events (0/239, 0%, 95% confidence interval [CI] 0%-1.6%), and no infant had congenital defects or malformations at delivery (0/231, 0%, 95% CI 0%-1.6%). The infants' physical development at birth (n = 231) and at 7 months (n = 222) was normal. Furthermore, 97.0% (224/231, 95% CI 93.9%-98.5%) of women achieved HBV DNA <5.3 log 10 IU/mL at delivery. The intention-to-treat and per-protocol infants' HBV-MTCT rates were 7.1% (17/239, 95% CI 4.5%-11.1%) and 0% (0/222, 95% CI 0%-1.7%) at the age of 7 months. Comparatively, 15.1% (18/119, 95% CI 9.8%-22.7%) vs 18.3% (22/120, 95% CI 12.4%-26.2%) of women in the 2 groups had mildly elevated alanine aminotransferase levels at 3 months and 6 months postpartum, respectively ( P = 0.507); notably, no one experienced alanine aminotransferase flare (0% [0/119, 95% CI 0%-3.1%] vs 0% [0/120, 0%-3.1%]).

DISCUSSION

Maternal TAF prophylaxis to prevent HBV-MTCT is generally safe and effective, and expected 8-week prenatal duration is feasible. ClinicalTrials.gov , NCT04850950.

Treatment burden in glomerular diseases: advances and challenges in immunosuppressive therapy

Glomerular diseases represent a significant global health challenge, complicated by the intricate management required for their treatment. We examine the treatment burden associated with the immunosuppressive therapies used to manage these conditions, focusing on the efficacy, side effects, and financial implications of commonly used medications such as glucocorticoids, mycophenolate mofetil (MMF), cyclophosphamide, calcineurin inhibitors and Rituximab. Immunosuppressive treatments, while effective in controlling disease activity, can result in a variety of adverse effects ranging from gastrointestinal symptoms and bone marrow suppression to increased infection risks, necessitating careful monitoring and dose adjustments to mitigate these risks. Hence, the need for a balanced approach in therapy management, incorporating regular monitoring and potential dose modifications to enhance patient outcomes while minimizing side effects. Additionally, these treatments have an economic impact, particularly in lower-income regions where access to medication and the cost of medication can limit patient outcomes. There have been certain advancements in treatment modalities, such as the use of enteric-coated formulations and tailored dosing schedules, which aim to improve drug tolerability and adherence. By addressing these critical aspects, we aim to shed light on the ongoing challenges and developments in the management of glomerular diseases, emphasizing the need for continued research and innovation in therapeutic strategies to reduce the overall treatment burden and improve the quality of life for affected individuals.

Hepatitis B Surface Antigen Seroclearance Rate After Stopping Nucleos(t)ide Analogues in Chronic Hepatitis B-A Systematic Review and Meta-Analysis

AIM

To identify factors influencing HBsAg seroclearance rates after stopping nucleos(t)ide analogue (NA) therapy in patients with chronic hepatitis B (CHB).

METHODS

We conducted a comprehensive literature search in databases from inception to July 2024. Subgroup analyses and meta-regression were performed to determine factors associated with HBsAg seroclearance, including ethnicity, HBV genotype, NA therapy duration, end-of-treatment (EOT) qHBsAg levels, HBeAg status, cirrhosis status, and follow-up duration.

RESULTS

The meta-analysis included 62 studies (n = 9867) with a pooled HBsAg seroclearance rate of 10% (95%CI: 8%-12%, I2 = 92%) after NA cessation. HBeAg-negative patients showed significantly higher rates than HBeAg-positive patients (11% vs. 5%, p = 0.030). Subgroup analysis revealed higher seroclearance with follow-up of >5 years (18%, p = 0.004), showing significantly higher rates were observed in studies with longer follow-up periods. Caucasians showed a higher rate (12%) than Asians (9%, p = 0.067). Studies adhering to AASLD, EASL, or APASL stopping rules showed no significant differences in rates. Patients with EOT qHBsAg ≤2.0 log IU/mL had higher rates (23%) than those with >2.0 log IU/mL (11%). Re-treated patients had lower seroclearance (6%) compared to those not re-treated (17%, p = 0.178). Meta-regression identified ethnicity, HBeAg status, and follow-up duration as significant contributors to heterogeneity. Egger's test showed no evidence of publication bias (p = 0.1928).

CONCLUSION

Our meta-analysis highlights the role of ethnicity, EOT qHBsAg levels, HBeAg-status, and follow-up duration in determining HBsAg seroclearance rates. These findings stress the need for personalized NA discontinuation strategies and further research on HBV genotypes and biomarkers to improve treatment outcomes and predict seroclearance more accurately.

Incidence of Osteopenia or Osteoporosis in Asian Patients With Chronic Hepatitis B

BACKGROUND

In an aging population, patients with chronic hepatitis B (CHB) may face a higher risk of osteopenia, osteoporosis, or fractures. We investigated the epidemiology and risk factors associated with osteopenia or osteoporosis in patients with CHB.

METHODS

This retrospective cohort study included patients ≥ 19 years who underwent bone mineral density (BMD) testing ≥ 2 times between 2005 and 2021 at Severance Hospital, Seoul, South Korea. Demographic factors and comorbidities for patients with or without CHB were matched based on a 1:4 ratio. Cox proportional hazard regression models were used to estimate hazard ratios to assess osteopenia or osteoporosis risk.

RESULTS

A total of 275 patients with CHB and 7868 patients without CHB who had normal BMD were analyzed. The incidence of osteopenia or osteoporosis in patients with and without CHB was 25.8% and 28.7%, respectively. After propensity score matching, in the second BMD test, 73.8%, 24.7%, and 1.5% of patients with CHB and 70.7%, 26.5%, and 2.8% of patients without CHB had normal BMD, osteopenia, and osteoporosis, respectively. Risk factors for osteopenia or osteoporosis in these patients were age, body mass index < 25, chronic kidney disease, and proton pump inhibitor use. There were no significant differences in cumulative hazard for patients with or without CHB.

CONCLUSIONS

Patients with or without CHB showed similar risks of osteopenia or osteoporosis. In addition to providing closer monitoring for patients with CHB with greater bone disease risk, further studies of bone disease in these patients may help to understand the factors that impact bone health.

Prompt initiation of durvalumab and tremelimumab for unresectable hepatocellular carcinoma in patients with chronic active hepatitis B: a phase 2 clinical trial

BACKGROUND

Chronic hepatitis B virus (HBV) infection is an etiology of HCC, but clinical trials using immune checkpoint inhibitors (ICIs) usually exclude patients with chronic active hepatitis B (serum HBV viral load > 2000 IU/mL). This study examined the safety and efficacy of concurrently administering the ICI and anti-HBV medications in this patient population.

METHODS

In this single-arm phase 2 clinical trial, we enrolled patients with advanced HCC and untreated chronic active hepatitis B. Patients received 1500 mg of durvalumab every 4 weeks alone or in combination with 300 mg of tremelimumab on day 1 (the STRIDE regimen). Anti-HBV treatment with entecavir was simultaneously initiated. The primary endpoint was the rate of HBV reactivation.

RESULTS

We enrolled 30 patients, whose mean baseline HBV viral load was 770,986 IU/mL. No patients experienced HBV reactivation or HBV-associated hepatitis. Hepatitis flare was noted in 8 (26.7%) patients, but none of them were associated with HBV reactivation. The objective tumor response rate was 10% and 25% for the durvalumab treatment alone and the STRIDE regimen, respectively.

CONCLUSION

For patients with chronic active hepatitis B, ICI therapy could be promptly initiated as long as anti-HBV medications were administered simultaneously.

CLINICAL TRIAL REGISTRATION

NCT04294498.

Updated recommendations for the management of hepatitis B, C, and E virus infections in patients with haematological malignancies and those undergoing haematopoietic cell transplantation: recommendations from the 9th European Conference on Infections in Leukaemia (ECIL-9)

Viral hepatitis remains a global health challenge and immune status affects outcomes. In patients with haematological malignancies, including haematopoietic stem-cell transplantation recipients, viral hepatitis can be life-threatening due to the direct effects of the virus or the need to modify or delay chemotherapy. Additionally, haematopoietic stem-cell donors with past or current viral hepatitis infections might transmit the virus to recipients. The growing recognition of hepatitis E virus (HEV), advances in haematological therapies, and the availability of direct-acting antivirals for hepatitis C virus (HCV), led the 2022 9th European Conference on Infections in Leukaemia (ECIL-9) to update the 2013 ECIL-5 guidelines on viral hepatitis. The ECIL organising committee convened a panel of 13 impartial international experts (all authors of this Review) in viral hepatitis, both within and outside the fields of haematological malignancies and immunosuppression. The ECIL-9 panel conducted a review of the literature on hepatitis B virus (HBV), HCV, and HEV, grading the evidence based on the European Society for Clinical Microbiology and Infectious Diseases system. The panel identified key clinical questions and outcomes and built on the recommendations established during ECIL-5. A consensus conference was held in Sofia Antipolis, France, from Sept 15-17, 2022, bringing together 49 experts from 19 countries. The ECIL-9 panel presented the proposed recommendations, which were revised following expert discussions. A final consensus on updated guidelines was reached in a second plenary session. The updated ECIL-9 guidelines provide evidence-based recommendations on the prevention, screening, treatment, and long-term surveillance of viral hepatitis in patients with haematological malignancies and haematopoietic cell transplantation recipients.

Association Between Viral Replication Activity and Postoperative Recurrence of HBV-Related Hepatocellular Carcinoma

BACKGROUND

Baseline viral replication activity influences the risk of hepatocellular carcinoma (HCC) development in patients with chronic hepatitis B virus (HBV) infection.

AIMS

To evaluate the impact of baseline viral replication activity on recurrence in HBV-related HCC after curative resection.

METHODS

A multinational retrospective cohort of 2384 patients with very early or early-stage HBV-related HCC who consecutively underwent curative resection and received antiviral therapy (AVT) between 2010 and 2018 was analysed. Patients were categorised into ongoing-AVT (previously on AVT with viral suppression) and initiation-AVT (initiated AVT at the time of resection) groups. HCC recurrence was compared between these two groups based on baseline viral replication activity.

RESULTS

During a median follow-up of 4.9 years, 1188 (49.8%) patients developed recurrence. Multivariable analysis showed similar recurrence risk between the ongoing-AVT and initiation-AVT groups (HR, 1.09; 95% CI, 0.96-1.24). However, in cirrhotic patients, the initiation-AVT group had a higher recurrence risk than the ongoing-AVT group (HR, 1.22; 95% CI, 1.02-1.45) but not in non-cirrhotic patients (HR, 0.90; 95% CI, 0.73-1.09). Intriguingly, in the non-cirrhotic initiation-AVT group, a parabolic association was observed between baseline HBV DNA levels and the risk of recurrence, with those having 5-6 log10 IU/mL HBV DNA levels showing significantly higher recurrence risk compared to the ongoing-AVT group (HR, 1.78; 95% CI, 1.32-2.42).

CONCLUSIONS

The association between HBV replication activity and the risk of HCC recurrence varied depending on cirrhosis, providing important insights for optimising the timing of AVT and post-operative surveillance strategies.

The Early On-treatment Stiffness Decline Attributed to the Improved Hepatic Inflammation in Fibrotic Chronic Hepatitis B

OBJECTIVES

Hepatic inflammation, the driver of fibrosis progression in liver disease, can impact the accuracy of liver stiffness measurement (LSM). We wondered whether the decline in LSM value during the early antiviral phase was mainly attributed to the control of hepatic inflammation or the regression of fibrosis in patients with fibrotic/cirrhotic chronic hepatitis B (CHB).

PATIENTS AND METHODS

The study cohort was composed of 82 patients with CHB who underwent antiviral and antifibrotic therapy at the Fifth Medical Center of PLA General Hospital. All patients had liver biopsies at both baseline and 72 weeks posttherapy. Liver pathology and clinical data, including the LSM value, were collected.

RESULTS

After 72 weeks of treatment, both the histologic activity index score and fibrosis score, as well as the LSM value, were significantly decreased ( P < 0.001), compared with their baseline values. The pretreatment correlation of LSM value with either histologic activity index score ( r = 0.526 vs r = 0.286) or fibrosis score ( r = 0.677 vs r = 0.587) was attenuated at 72 weeks. Notably, logistic regression analysis revealed that the improvement in inflammation (odds ratio = 1.018, 95% CI: 1.002-1.031, P = 0.023) but not fibrosis (odds ratio = 0.994, 95% CI: 0.980-1.009, P = 0.414), had an impact on the change in LSM values between baseline and at 72-week treatment.

CONCLUSIONS

The findings of this study suggest that in patients with fibrotic CHB receiving antiviral medication, the early phase reduction in LSM value was related to improved hepatic inflammation rather than fibrosis regression.

Association of nucleos(t)ide analogue therapy with Parkinson disease in chronic hepatitis B patients

Prolonged therapy using nucleos(t)ide analogs (NUC) is inevitable in patients with chronic hepatitis B (CHB) infection, but its long-term impact on Parkinson's disease (PD) risk remains unclear. This study evaluated the association between NUC therapy and PD incidence in a nationwide CHB cohort. The study population comprised the National Health Insurance Service claims database from January 1, 2013, to December 31, 2013, only included treatment naïve CHB patients and those without previously diagnosed with PD. Participants were followed until PD diagnosis or study completion. The primary outcome was PD incidence, comparing patients who initiated NUC therapy at cohort entry with those who did not. Over the 7.9-year study period, the incidence rate of PD in NUC-treated patients was 1.48 per 1000 persons, compared to 1.95 per 1000 persons in the untreated group. In an adjusted competing risk model, the 3-year follow-up showed a statistically significant reduction in risk (hazard ratio [HR]: 0.61; 95% confidence interval [CI] 0.39-0.97). In the propensity score-matched cohort of 18,365 pairs, the cumulative incidence during 2-4 years of follow-up was significantly lower in the NUC-treated group compared to the untreated group. However, no statistically significant difference in cumulative PD incidence was observed between the groups at the early or late stages of the follow-up period. NUC therapy initially reduced PD incidence, but this protective effect diminished over time, indicating a time-varying effect. Regular PD screening may be needed for long-term NUC users.

Hepatocellular carcinoma in people living with HIV

People living with HIV (PLWH) carry a higher risk of developing chronic liver disease and hepatocellular carcinoma (HCC). This relates to shared transmission pathways of HIV and viral hepatitis and a plethora of direct and indirect effects of HIV in the progression of chronic liver disease and HCC. In absence of active cancer treatment, the prognosis of PLWH affected by HCC is worse compared to matched controls without HIV. Evolving evidence suggests that PLWH may receive curative therapies including liver transplantation, loco-regional and systemic anti-cancer therapy for HCC with comparable benefit than people without HIV, underscoring that well controlled HIV infection should not be a barrier to the delivery of cancer care. Nevertheless, PLWH have historically been excluded from interventional clinical trials, and most of the evidence supporting clinical decision making in this population comes from small retrospective studies, adding further challenges to the management of PLWH affected by HCC. Furthermore, whether the biology of the tumour and its microenvironment is influenced by HIV and affects response to treatment is incompletely understood. In this review we summarise the current understanding of pathophysiology, screening and management of HCC in PLWH and discuss the persisting challenges and disparities in care which may contribute to clinical outcome in PLWH.

Chronic active and chronic inactive hepatitis B virus infection: Comparative study of genetic polymorphism and blood profile measures

INTRODUCTION

Hepatitis B virus (HBV) is a significant cause of chronic hepatitis, leading to liver complications such as cirrhosis and hepatocellular carcinoma. Toll-like receptors (TLRs) are critical in the immune response to HBV. This study investigates the TLR3 1377 C/T polymorphism's association with clinical outcomes in chronic hepatitis B patients.

MATERIALS AND METHODS

A case-control study included 136 participants (66 cases and 70 controls). The patients were categorized as having chronic active or inactive hepatitis B based on serological, biochemical, and molecular parameters. TLR3 1377 C/T polymorphism was analyzed using PCR-RFLP. The correlation between TLR3 genotypes, HBeAg status, liver enzyme levels (ALT and AST), and symptomatic presentation was assessed.

RESULTS

Among the 66 cases, the CC genotype was more frequent in males with chronic active hepatitis (14 males, 5 females), but no significant gender-based difference was observed in genotype distribution. A significant association was found between the CC genotype and symptomatic presentation in chronic active cases (P = 0.015). However, no significant association was detected between TLR3 genotypes and HBeAg status (P > 0.05). Elevated ALT and AST levels were more prevalent in chronic active cases.

CONCLUSIONS

The TLR3 1377 C/T polymorphism, particularly the CC genotype, may influence the clinical presentation of chronic hepatitis B, particularly in symptomatic cases. However, its impact on HBeAg status and overall chronicity appears limited. Further studies are needed to clarify the role of TLR3 polymorphisms in HBV pathogenesis and their potential as therapeutic targets.

Head-to-Head Comparison of Long-Term HCC Risk of Antivirals-Treated Versus Untreated Low-Level Viremia in HBV-Compensated Cirrhosis

BACKGROUND

Among patients with hepatitis B virus (HBV)-infected compensated cirrhosis and low-level viremia, there are limited data for comparative outcomes between those treated with oral nucleos(t)ide analogs versus those not. We conducted a large, multi-ethnic, multi-center study to examine the impact of antiviral treatment (AVT) on long-term hepatocellular carcinoma (HCC) risk for compensated cirrhosis and low-level viremia.

METHODS

Patients with compensated cirrhosis and low-level viremia (serum HBV-DNA 20-2000 IU/mL) at baseline or before AVT were screened for eligibility from 19 hospitals in South Korea, Singapore, and Japan. The primary outcome was HCC development, compared between those receiving AVT versus those untreated throughout follow-up.

RESULTS

Among 848 patients (mean age 55.7 years and 66.9% male), AVT (n = 233) was associated with significantly lower annual HCC incidence compared to non-AVT (n = 615); 1.72/100 versus 2.99/100 person-years (PY), respectively (p = 0.033). Multivariable Cox-regression analyses determined that AVT was associated with significantly lower HCC risk, compared to non-AVT (adjusted HR [HR] 0.514, 95% confidence interval [CI] 0.271-0.976; p = 0.042). In a landmark analysis, HCC incidence was similar between two groups until 18 months, but after this landmark, the treated group had the significantly lower HCC risk compared to untreated group (p = 0.012). Furthermore, propensity score-matching analysis consistently showed that AVT was associated with significantly lower HCC risk, compared to non-AVT; the annual HCC incidence of 1.45/100 PYs versus 2.73/100 PY, respectively (p = 0.043).

CONCLUSIONS

Patients with compensated cirrhosis and low-level viremia may benefit from long-term AVT, highlighting appropriate amendment of reimbursement guidelines.

Risk of Hepatocellular Carcinoma Decreases After Antiviral Therapy-Induced HBsAg Seroclearance

BACKGROUND

Antiviral therapy (AVT) reduces the risk of hepatitis B virus-related hepatocellular carcinoma (HCC).

AIMS

The difference in risk of HCC after hepatitis B surface antigen (HBsAg) seroclearance to the AVT status was explored.

METHODS

Patients with chronic hepatitis B who achieved HBsAg seroclearance were retrospectively evaluated. The primary outcome was the development of HCC after HBsAg seroclearance.

RESULTS

Of the study population, 1280 (84.2%) and 241 (15.8%) patients achieved HBsAg seroclearance without (spontaneous clearance group) and with AVT (AVT-induced clearance group), respectively. HCC cumulative incidence was comparable between the two groups (hazard ratio [HR] = 0.461; log-rank test, p = 0.197), whereas it was significantly lower in the AVT-induced HBsAg clearance group than in the spontaneous HBsAg clearance group in inverse probability of treatment weighting analysis (HR = 0.442; log-rank test, p = 0.004). In multivariate analysis, spontaneous HBsAg clearance, albumin-bilirubin (ALBI) grade ≥ 2, cirrhosis, and platelet count < 50 × 109/L were independently associated with the increased risk of HCC. The newly established antiviral therapy, cirrhosis, ALBI, and platelet count (ACAP) scores had a C-index of 0.765, and the time-dependent areas under the curve of HCC prediction at 5 and 8 years were 0774 and 0.823, respectively.

CONCLUSION

The risk of HCC differed according to the AVT status after HBsAg seroclearance.

Relationship Between Nucleos(t)ide analogue antiviral response time and prognosis in Chronic Hepatitis B: conclusions depend on baseline viral load and HBeAg status

Introduction

Current guidelines for changing antiviral therapy regimens do not consider different baseline statuses. This study aimed to investigate whether significant prognostic differences exist among patients achieving virological response at various time points and whether these differences vary by viral load and HBeAg status.

Methods

This retrospective cohort study included 1,037 patients, who were classified based on their baseline viral load (high viral load, HVL, ≥ 7log10 IU mL-1: 522 individuals; or non-HVL, < 7log10 IU mL-1: 515 individuals) and HBeAg status (positive: 668 individuals; or negative: 369 individuals). Based on the virological response time, patients were grouped separately using 48 weeks and 96 weeks as the boundaries. The prognoses across these groups were evaluated and compared.

Results

Patients in the within-48-week group, 48-96-week group, and after-96-week group exhibited no significant difference in the incidence of liver disease progression (5.08% vs 4.38% vs 9.61%, p = 0.33). For HVL or HBeAg-positive patients, there was no significant difference in the cumulative incidence of liver disease progression between the within-48-week group and the 48-96-week group. In contrast, for non-HVL or HBeAg-negative patients, the cumulative incidence of liver disease progression was significantly higher in the after-48-week group than in the within-48-week group. Only the after-96-week group showed a significant increase in maintained virological response rate (p = 0.04).

Conclusion

Antiviral treatment should be adjusted at 48 weeks for non-HVL or HBeAg-negative patients. For HVL and HBeAg-positive patients, we suggest changing the antiviral treatment plan to 96 weeks.

FTY720 alleviates HBV-mediated inflammatory liver injury through a dual role of inhibiting lymphocyte trafficking and viral replication

BACKGROUND

The host immune response plays a critical role in clearing hepatitis B virus infection. However, in chronic hepatitis B, this response fails to eliminate the virus, leading to recurrent inflammation, liver tissue damage, and a gradual progression from hepatitis to fibrosis, and eventually, hepatocellular carcinoma. Reducing liver injury while enhancing antiviral efficacy remains a key objective in hepatitis B virus treatment development. Our previous research revealed a close association between hepatitis B virus infection and the sphingosine 1-phosphate signaling pathway. Consequently, this study aims to explore the dual role of FTY720, an immune modulator that targets sphingosine- 1-phosphate receptor, in hepatitis B virus-related liver injury.

METHODS

In this study, The peripheral blood leukocyte count and the expression of sphingosine 1-phosphate receptor on lymphocytes were compared between chronic hepatitis B patients and healthy controls. In vitro experiments were conducted to evaluate the direct antiviral effects of FTY720 on two hepatitis B virus models: HepG2.2.15 and Huh7 cells transfected with pUC19-HBV1.3. Additionally, the study investigated the influence of FTY720 on the chemotaxis of peripheral blood mononuclear cells induced by the supernatant of hepatitis B virus-infected HepG2-NTCP cells. An in vivo model using hepatitis B virus hyperbaric hydrodynamic injection in mice was also employed to assess the impact of FTY720 on both HBV replication and hepatic lymphocyte infiltration.

RESULTS

Peripheral blood lymphocyte counts were reduced, while sphingosine 1-phosphate receptor expression was elevated in chronic hepatitis B patients compared to healthy controls. Simultaneously, antiviral therapy solely utilizing nucleotide analogues could not fully restore the peripheral blood lymphocyte count in patients with chronic hepatitis B. In vitro, FTY720 effectively inhibited hepatitis B virus replication in two models: HepG2.2.15 cells containing hepatitis B virus virions and pUC19-HBV1.3-transfected Huh7 cells. Furthermore, supernatants from hepatitis B virus-infected HepG2-NTCP cells induced increased lymphocyte chemotaxis, which was suppressed by FTY720. In a hepatitis B virus mouse model, FTY720 significantly reduced viral DNA and protein levels, while also decreasing inflammatory hepatocyte necrosis, liver lymphocyte infiltration, and sphingosine 1-phosphate receptor expression on circulating lymphocytes.

CONCLUSIONS

These findings suggest that FTY720 can inhibit both hepatitis B virus replication and hepatitis B virus-related liver damage by modulating lymphocyte migration. Further investigation into the specific mechanisms underlying the interaction between FTY720 and hepatitis B virus is warranted.

Entecavir for children and adults with chronic hepatitis B

RATIONALE

Chronic hepatitis B is a major worldwide public health concern. Entecavir, one nucleos(t)ide analogue antiviral therapy option, is recommended as the first-line drug for chronic hepatitis B in many clinical guidelines. However, none of the guideline recommendations are based on the findings of a systematic review with meta-analysis, where entecavir versus no treatment or placebo are compared directly.

OBJECTIVES

To evaluate the benefits and harms of entecavir versus no treatment or placebo in children and adults with chronic hepatitis B, who are either hepatitis B e-antigen (HBeAg)-positive or HBeAg-negative.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, Cochrane Central Register of Controlled Trials, MEDLINE Ovid, Embase Ovid, three other databases, online trial registries, and reference lists, and contacted authors. The latest search was on 19 July 2024.

ELIGIBILITY CRITERIA

We included randomised clinical trials comparing entecavir versus no treatment or placebo in children or adults, or both, with chronic hepatitis B, and irrespective of treatment history with other antiviral drugs and other viral co-infections. We allowed co-interventions when administered equally to all intervention groups.

OUTCOMES

The outcomes reported in this abstract and in the summary of findings table are all-cause mortality, health-related quality of life, and proportion of people with serious adverse events at the longest follow-up.

RISK OF BIAS

We used the Cochrane RoB 2 tool to assess risk of bias in the included trials.

SYNTHESIS METHODS

We used a random-effects model to meta-analyse outcome results, where possible, and presented the results as a risk ratio (RR) with 95% confidence interval (CI). Where there was considerable heterogeneity, we performed a narrative analysis. We used a fixed-effect model for sensitivity analysis. We used GRADE to evaluate the certainty of evidence.

INCLUDED STUDIES

We included 22 randomised clinical trials (published from 2005 to 2022) with 2940 participants diagnosed with chronic hepatitis B. All trials had a parallel-group design. The experimental intervention was oral entecavir, with a follow-up duration of 5 weeks to 228 weeks. The comparator in 12 trials was no treatment, and in 10 trials was placebo. Fourteen trials equally administered co-interventions to the trial participants in the entecavir and no treatment and placebo groups. One trial included participants between 14 years and 55 years of age, one trial included only children, 19 trials included only adults, and one trial did not provide the age of participants.

SYNTHESIS OF RESULTS

Twenty trials contributed data to the quantitative analysis. Ten trials (1379 participants) reported all-cause mortality with a mean follow-up duration of 48.9 weeks (range 5 to 100 weeks). The result was not estimable because no deaths occurred in any of the entecavir and no treatment or placebo groups. None of the trials provided data on health-related quality of life. We are very uncertain about the effect of entecavir versus no treatment or placebo on the proportion of people with serious adverse events (RR 0.66, 95% CI 0.33 to 1.32; absolute risk difference 22 fewer per 1000 (from 44 fewer to 21 more); 15 trials, 1676 participants; very low-certainty evidence). The mean follow-up duration was 58.4 weeks (range 5 weeks to 228 weeks). We downgraded the certainty of evidence for these outcomes to very low, mainly because the overall risk of bias in most trials was with some concerns or high, and serious imprecision (no events or few events).

AUTHORS' CONCLUSIONS

Given the issues of risk of bias and insufficient power of the included trials and the very low certainty of the available evidence, we could not determine the effect of entecavir versus no treatment or placebo on critical outcomes such as all-cause mortality and serious adverse events. There is a lack of data on health-related quality of life. Given the first-line recommendation and wide usage of entecavir in people with chronic hepatitis B, further evidence on clinically important outcomes, analysed in this review, is needed.

FUNDING

This Cochrane review had no dedicated funding.

REGISTRATION

Registration: Entecavir for children and adults with chronic hepatitis B, CD015536 via DOI 10.1002/14651858.CD015536.

Predictive value of soluble PD-1 for HBsAg loss in HbeAg-negative patients with chronic hepatitis B: results from a prospective study

BACKGROUND

Soluble PD-1 (sPD-1) has emerged as a potential biomarker in chronic hepatitis B (CHB), but its predictive value for treatment response remains unclear.

OBJECTIVE

To examine the relationship between sPD-1 dynamics and HBsAg loss in HBeAg-negative CHB patients undergoing IFN-based therapy and assess the potential of sPD-1 as a biomarker for treatment response.

METHODS

We enrolled 222 HBeAg-negative CHB patients from a prospective study. Patients received at least 48 weeks of PEG-IFNα-2b therapy and were grouped based on HBsAg status at week 48 (loss vs. persistence). Peripheral blood sPD-1 levels were measured by ELISA, and PD-1 expression on CD4+ and CD8+ T cells was analyzed by flow cytometry. Propensity score matching (PSM) and Cox regression were applied to identify predictors of HBsAg loss.

RESULTS

Among the patients, 38.7% (86/222) achieved HBsAg loss. After PSM, both the HBsAg loss and HBsAg persistence groups included 74 patients, respectively. A reduction in HBsAg of more than 70% at week 12 (p = 0.012) and baseline sPD-1 level lower than 100 pg/mL (p = 0.016) were identified as independent predictors of HBsAg loss. sPD-1 levels showed a positive correlation with HBsAg levels, whereas PD-1 expression on peripheral CD4+ and CD8+ T cells demonstrated no significant association with HBsAg levels, suggesting that sPD-1 may better reflect systemic immune status.

CONCLUSIONS

sPD-1 may serve as a potential biomarker for predicting HBsAg loss in HBeAg-negative CHB patients undergoing IFN-based therapy.

CT-based artificial intelligence system complementing deep learning model and radiologist for liver fibrosis staging

Noninvasive methods for liver fibrosis staging are urgently needed due to its significance in predicting significant morbidity and mortality. In this study, we developed an automated DL-based segmentation and classification model (Model-C). Test-time adaptation was used to address data distribution shifts. We then established a deep learning-radiologist complementarity decision system (DRCDS) via a decision model determining whether to adopt Model-C's diagnosis or defer to radiologists. Model-C (AUCs of 0.89-0.92) outperformed models based on liver (AUCs: 0.84-0.90) or spleen (AUCs: 0.69-0.70). With test-time adaptation, the Obuchowski index values of Model-C in three external sets improved from 0.81, 0.73, and 0.73 to 0.85, 0.85, and 0.81. DRCDS performed slightly better than Model-C or senior radiologists, with 73.7%-92.0% of cases adopting Model-C's diagnosis. In conclusion, DRCDS could diagnose liver fibrosis with high accuracy. Additionally, we provided solutions to model generalization and human-machine complementarity issues in multi-classification problems.

Impact of nucleos(t)ide analogue therapy on the incidence of Alzheimer's disease in patients with chronic hepatitis B virus infection

BACKGROUND

Long-term therapy with nucleos(t)ide analogs (NUCs) is inevitable for chronic hepatitis B (CHB) patients. However, how NUC therapy on the developing Alzheimer's disease (AD) in these patients remains controversial.

METHODS

This retrospective cohort study used the Korean National Health Insurance Service claims database from January 1, 2013, to December 31, 2013, treatment naïve CHB patients and those without previously diagnosed with AD. Participants were followed from the index date until either the diagnosis of AD or the study's conclusion on December 31, 2021. The primary outcome was the incidence of AD, compared between the group with initiated NUC therapy (n = 18,365) at cohort entry and the group without NUC therapy (n = 212,820).

RESULTS

During the study, 416 patients were diagnosed with AD. After propensity-score matching (18,365 pairs), the 5- to 7-year follow-up showed a significantly lower hazard ratio (HR) in the NUC-treated group compared to the untreated group (HR 0.31-0.40), with HRs remaining constant over time. Subgroup analysis showed more pronounced benefits of NUC therapy in patients under 65 years (HRs: 0.22 vs. 1.23; P < 0.05) and those without dyslipidemia (HRs: 0.14 vs. 1.09; P < 0.05). Protective effects were also observed across subgroups with hypertension, chronic kidney disease, heart disease, and a history of brain trauma, consistent with AD risk factor trends.

CONCLUSIONS

Our study analyses suggest that NUC therapy appears to have a protective effect against the development of AD in patients with CHB.

Virological and Biochemical Effects of Tenofovir Alafenamide in Different Patient Groups With Chronic Hepatitis B Virus Infection in Real-World Cohort

Hepatitis B virus (HBV) infection is an important health concern worldwide. HBV infection can lead to acute hepatitis, cirrhosis, hepatocellular carcinoma, liver failure, and death. Nucleos(t)ide analogs (NAs) form the core of the HBV treatment. The safety and efficacy of NAs in long-term follow-up are still critical issues. We enrolled 225 consecutive patients with at least 12 months of longitudinal follow-up using tenofovir alafenamide (TAF), including 39 antiviral naïve and 186 antiviral experienced patients. In the treatment-experienced group, the main reasons for switching from other NAs to TAF were renal dysfunction and osteoporosis. Renal outcome, lipid profile, virological response, and ALT normalization under the TAF treatment were evaluated. Age > 60 years, liver transplant recipients, and patients with decompensated cirrhosis were evaluated separately, as well as the total cohort. Phosphorus levels increased especially in hypophosphatemic individuals, eGFR levels also increased slightly but statistically significantly, and the remarkable improvement in eGFR stages was observed in the eGFR < 60 mL/min/1.73 m2 group. A minimal increase in LDL-c levels occurred after TAF treatment, which did not reach statistical significance. Total cholesterol and HDL-c levels increased significantly, while triglyceride levels remained unchanged. In the total cohort, HBV-DNA was strongly suppressed in either treatment-naïve or experienced patients. ALT and AST levels decreased with the TAF treatment, but ALT normalization rate did not change significantly. No serious adverse events associated with TAF occurred, and discontinuation was not required in the total cohort. Our findings support that TAF treatment is well-tolerated and effective in patients with chronic HBV infection.

Investigation of Hepatitis C, D, and HIV Seroprevalence and Evaluation of APRI and FIB-4 Scores in HbsAg-Positive Patients

This study aimed to assess the prevalence of HDV (hepatitis delta virus), HCV (hepatitis C virus), and HIV (human immunodeficiency virus) coinfections among HBsAg-positive patients and to determine the severity of liver fibrosis and biochemical markers. Furthermore, the study sought to evaluate the noninvasive fibrosis scores (APRI and FIB4) in predicting the severity of liver disease in patients with hepatitis B. A retrospective analysis of 1434 patients with chronic HBV admitted between January 2020 and December 2024 was conducted at Sincan Tertiary Hospital. The positivity rates of the following antibodies were the focus of the study: anti-HDV, anti-HCV, and anti-HIV. In addition to these, the levels of HIV-RNA, HCV-RNA and HBV-DNA, as well as several biochemical markers (ALT, AST, INR, albumin, bilirubin and platelet count) were also evaluated. The APRI and FIB-4 scores were calculated. Of the 1434 patients, 49 (3.4%) tested positive for anti-HDV, 784 were screened for anti-HCV, and 749 were screened for anti-HIV. The positivity rates were 3.4% (27/784) and 3.4% (26/749), respectively. According to ROC analysis, the FIB-4 score had a statistically significant effect on predicting anti-HDV negativity (AUC = 0.59, p = 0.031). However, the APRI score was not a significant predictor for anti-HDV positivity (AUC = 0.53, p > 0.05). APRI and FIB-4 scores did not have a statistically significant discriminatory power in predicting anti-HCV and anti-HIV positivity (p > 0.05). The cut-off value for the FIB-4 score in predicting anti-HDV positivity was 1.72, with a sensitivity of 61.4% and a specificity of 42.9% (p = 0.031). Among the HCV/RNA-positive patients (n = 5), all were male, and two also had positive anti-HBe results with undetectable HBV/DNA levels. One HIV/RNA-positive patient, a foreign national, was confirmed to have HIV/HBV/HDV infection. All HBsAg-positive patients should undergo routine anti-HDV testing. Vaccination programmes are vital in preventing the spread of HDV. Dual screening strategies are essential for identifying infected individuals and developing prevention and treatment programmes. Anti-HDV positivity indicates advanced liver fibrosis, emphasising the importance of screening and monitoring. However, the limited accuracy of the APRI and FIB-4 scores for detecting coinfections highlights the need to integrate noninvasive methods with molecular diagnostics for precise management.

Virologic Response at 12 Months Predicts Lower Hepatocellular Carcinoma Risk in Genotype D Chronic Hepatitis B Patients Treated with Nucleos(t)ide Analogues

Background/Objectives: Hepatitis B virus (HBV) is a virus that can cause chronic hepatitis B (CHB) in humans, leading to cirrhosis and hepatocellular carcinoma (HCC). In this study, we aimed to investigate the relationships between early ALT normalization (at 12 months), the virologic response in CHB patients, and the risk of HCC development. Methods: Data from a retrospective cohort study involving 616 chronic hepatitis B patients were used. The effects of ALT normalization and virologic response on the risk of developing HCC at 12 months of treatment were analyzed. Results: During a median treatment duration of 70.9 months, 36 (5.8%) HCC cases were detected in the total patient population. ALT normalization was detected in 68.83% of patients at 12 months of treatment. The rate of HCC in the group with early ALT normalization was lower than that in the group without ALT normalization, but this difference was not statistically significant (5% vs. 7.8%, p = 0.161). At the end of 12 months of treatment, virologic response was detected in 80.68% of the patients. The rate of patients developing HCC was significantly lower in the virologic response group (4.8% vs. 10.1%, p = 0.028). However, the risk of developing HCC was also significantly higher in the virologically unresponsive group, according to the virologic response at 12 months (p = 0.034). Conclusions: According to the results of this study, achieving virologic response at the end of 12 months in genotype D CHB patients treated with nucleos(t)ide analogs (NAs) reduces the risk of developing HCC.

Hepatitis B virus resistance to nucleos(t)ide analogue therapy: WHO consultation on questions, challenges, and a roadmap for the field

In this Review, we summarise outputs from a multidisciplinary consultation convened by WHO between July 11 and 13, 2023, to discuss hepatitis B virus (HBV) drug resistance (HBVDR). Treatment of chronic HBV infection with highly effective nucleos(t)ide analogue agents, tenofovir and entecavir, is a crucial intervention that supports the global goal of elimination of HBV infection as a public health threat. The risk of HBVDR as a threat to treatment outcomes is currently considered low from a public health perspective; however, drug resistance can influence individual outcomes, particularly among those who are treatment-experienced. We highlight the need to develop appropriate prevention, monitoring, and surveillance approaches for HBVDR, to support investment in the global scale-up of HBV diagnosis and treatment. Recommendations for the HBVDR field will ultimately be incorporated into a WHO integrated Global Action Plan for drug-resistant HIV, viral hepatitis, and priority sexually transmitted infections.

Discussion on the duration of response following HBsAg clearance in patients with chronic hepatitis B treated with PegIFNα-2b

Aim

Functional cure strategies based on interferon therapy for chronic hepatitis B (CHB) are gaining increasing attention among clinicians. However, studies investigating the duration of response after achieving HBsAg clearance with interferon treatment are limited. This study aims to explore the patterns of sustained response following HBsAg clearance in patients treated with pegylated interferon alpha-2b (PegIFNα-2b) through long-term follow-up, providing guidance for clinical practice.

Methods

We collected data from CHB patients who achieved HBsAg clearance and were treated with either PegIFNα-2b monotherapy or in combination with nucleos(t)ide analogs (NAs) at Tianjin Third Central Hospital from January 2018 to May 2024. Regular follow-up assessments were conducted to observe the dynamic changes in HBsAg, HBV DNA, and liver function during the follow-up period. We recorded the time to HBsAg reversion (defined as HBsAg ≥ 0.05 IU/mL), analyzed the patterns of HBsAg reversion, and investigated the optimal time points for evaluating sustained HBsAg clearance.

Results

A total of 173 patients with CHB or compensated hepatitis B cirrhosis were included. The mean age was 41.5 ± 9.0 years, with 16.19% of patients having compensated cirrhosis. The median follow-up duration was 89.3 weeks (range: 18.6 to 289.1 weeks). HBsAg reversion occurred in 26 patients, yielding a reversion rate of 15.03% (26/173). Among these 26 patients, 50% (13/26) experienced reversion within 24 weeks, and 80.77% within 48 weeks; thereafter, the number of reversions gradually decreased. At 48 weeks post-treatment cessation, the HBsAg sustained response rate was 95.45%, stabilizing at 100% after 120 weeks. Among patients with regular follow-ups, virtually none experienced reversion beyond 72 weeks. At the time of HBsAg reversion, all 26 patients exhibited normal alanine aminotransferase (ALT), aspartate aminotransferase (AST), and total bilirubin (TBIL) levels, with a median HBsAg level of 0.70 IU/mL (range: 0.05 to 8.13 IU/mL), and only one patient showing low-level positive HBV DNA (117 IU/mL). No adverse events, including liver failure, decompensation, or hepatocellular carcinoma, occurred during the follow-up period.

Conclusions

Patients with chronic hepatitis B treated with PegIFNα-2b demonstrated favorable long-term persistence of HBsAg clearance. However, there remains a risk of HBsAg reversion after treatment cessation, predominantly within the first 48 weeks. HBsAg sustained response (HSR) at 48 weeks post-treatment is a critical follow-up time point for CHB patients post-HBsAg clearance, with HSR at 72 weeks potentially representing an ideal follow-up timeframe, while HSR at 120 weeks may serve as a marker for extended follow-up.

A study on pregenomic RNA and factors in the pregnant and postpartum women with chronic HBV infection based on real world

Introduction

Most studies have focused on mother-to-child transmission and postpartum hepatitis flares. We aimed to evaluate the expression profile of pregenomic RNA (pgRNA) and its associated factors in patients with chronic HBV infection (CHB) during pregnancy and postpartum.

Methods

A total of 134 pregnant and 100 postpartum CHB patients were enrolled, and serum pgRNA levels were quantified.

Results

Significant differences in clinical characteristics were noted between pregnant and postpartum CHB patients, but there was no significant difference in pgRNA levels between the two groups. When HBV DNA and HBV antigen levels were low, the corresponding pgRNA detection rate decreased. pgRNA was positively correlated with DNA and HBV antigens in the pregnant and postpartum CHB patients. In the pregnant group, antiviral treatment was an independent risk factor for pgRNA levels. In the postpartum period, HBeAg levels and antiviral treatment were independent risk factors for pgRNA levels. Considering that patients receiving antiviral treatment often have a high DNA load or HBeAg positivity, the DNA level and HBeAg essentially affect pgRNA levels.

Conclusion

pgRNA levels differ between pregnant and postpartum patients, and this difference is of great significance for the diagnosis and management of these particular groups.

Predictive value of HBeAg titer dynamics for HBsAg clearance in pediatric chronic hepatitis B

Introduction

Achieving functional cure of chronic hepatitis B (CHB), characterized by the loss of HBV DNA and HBsAg, remains challenging in adults but demonstrates higher success rates in children. Elucidating the factors influencing HBsAg loss in pediatric patients is crucial for optimizing treatment strategies. This study aimed to evaluate the predictive value of HBeAg titer dynamics for HBsAg clearance in pediatric CHB and develop a predictive model incorporating these dynamics.

Material and methods

This retrospective cohort study analyzed 119 children aged 1-18 years with CHB treated with nucleos(t)ide analogues. Patient outcomes were evaluated using two independent classification approaches: HBsAg loss status and age stratification (≤6 vs. >6 years). Treatment response was assessed through longitudinal HBeAg titer measurements during the first 12 months. Based on identified predictors, a logistic regression model was developed incorporating age and HBeAg titer dynamics to predict HBsAg clearance probability.

Results

The study population exhibited a median age of 6.2 years. Factors associated with HBsAg loss encompassed younger age, female sex, and absence of breakthrough. In multivariate analysis, younger age was identified as the only significant factor. The cumulative HBsAg loss rate demonstrated markedly higher values in the ≤6 years group (Hazard ratio 7.69). HBeAg titer decline exhibited significantly steeper trajectories in the HBsAg loss group. The developed predictive model, "Log Odds = -1.182 + 0.308 × log_reduction-0.205 × age", demonstrated good performance with high accuracy.

Conclusions

Early HBeAg titer dynamics combined with age at treatment initiation may serve as useful predictors of HBsAg clearance in pediatric CHB. Our predictive model, utilizing readily available semi-quantitative HBeAg measurements, could potentially assist clinicians in therapeutic decision-making and individualized treatment strategies.

Machine Learning-Based Model Used for Predicting the Risk of Hepatocellular Carcinoma in Patients with Chronic Hepatitis B

Object

Currently, predictive models that effectively stratify the risk levels for hepatocellular carcinoma (HCC) are insufficient. Our study aimed to assess the 10-year cumulative risk of HCC among patients suffering from chronic hepatitis B (CHB) by employing an artificial neural network (ANN).

Methods

This research involved 1717 patients admitted to Beijing Ditan Hospital of Capital Medical University and the People's Liberation Army Fifth Medical Center. The training group included 1309 individuals from Beijing Ditan Hospital of Capital Medical University, whereas the validation group contained 408 individuals from the People's Liberation Army Fifth Medical Center. By performing a univariate analysis, we pinpointed factors that had an independent impact on the development of HCC, which were subsequently employed to create the ANN model. To evaluate the ANN model, we analyzed its predictive accuracy, discriminative performance, and clinical net benefit through measures including the area under the receiver operating characteristic curve (AUC), concordance index (C-index), and calibration curves.

Results

The cumulative incidence rates of HCC over a decade were observed to be 3.59% in the training cohort and 4.41% in the validation cohort. We incorporated nine distinct independent risk factors into the ANN model's development. Notably, in the training group, the area under the receiver operating characteristic (AUROC) curve for the ANN model was reported as 0.929 (95% CI 0.910-0.948), and the C-index was 0.917 (95% CI 0.907-0.927). These results were significantly superior to those of the mREACHE-B(0.700, 95% CI 0.639-0.761), mPAGE-B(0.800, 95% CI 0.757-0.844), HCC-RESCUE(0.787, 95% CI 0.732-0.837), CAMD(0.760, 95% CI 0.708-0.812), REAL-B(0.767, 95% CI 0.719-0.816), and PAGE-B(0.760, 95% CI 0.712-0.808) models (p < 0.001). The ANN model proficiently categorized patients into low-risk and high-risk groups based on their 10-year projections. In the training cohort, the positive predictive value (PPV) for the incidence of liver cancer in low-risk individuals was 92.5% (95% CI 0.921-0.939), whereas the negative predictive value (NPV) stood at 88.2% (95% CI 0.870-0.894). Among high-risk patients, the PPV reached 94.6% (95% CI 0.936-0.956) and the NPV was 90.2% (95% CI 0.897-0.917). These results were also confirmed in the independent validation cohort.

Conclusion

The model utilizing artificial neural networks demonstrates strong performance in personalized predictions and could assist in assessing the likelihood of a 10-year risk of HCC in patients suffering from CHB.

Anti-HBs Levels 18-26 Years After the Initial Hepatitis B Vaccination Series in a Low-to-Medium Prevalence Region: Is a Booster Dose or a Second Vaccine Series Necessary?

This cross-sectional study aimed to evaluate the persistence of immunity provided by hepatitis B (Hep B) vaccine 18-26 years after primary vaccination among 628 participants. Blood samples were collected for Hep B surface antigen (HBsAg), anti-HBs antibody (anti-HBs), and core antibody (anti-HBc) analyses. For participants with anti-HBs levels of < 10 mIU/mL, booster dose was administered and anti-HBs titers were monitored 4-6 weeks after vaccination was completed. If the response to Hep B vaccine was inadequate, two additional Hep B vaccine doses were administered. Of the 628 participants, 269 were excluded based on the exclusion criteria, and 359 were included in the final analysis. Three participants were found to be HBsAg-positive, resulting in an HBsAg carrier rate of 0.83%. Moreover, 55.4% participants had anti-HBs levels of ≥ 10 mIU/mL, with a geometric mean concentration (GMC) of 82.59 mIU/mL (95% confidence interval [CI]). Among 125 participants with anti-HBs levels of < 10 mIU/mL, 93.1% reached anti-HBs levels of ≥ 10 mIU/mL after booster dose, with a GMC of 493.47 mIU/mL. A prebooster anti-HBs cutoff level of 1.28 mIU/mL was predictive for an immune response, with a sensitivity and specificity of 71.2% and 71.4%, respectively (p = 0.001, 95% CI, likelihood ratio: 2.49). Among 14 participants unresponsive to the booster dose, 78.5% responded to the second vaccine series with a GMC of 670.82 mIU/mL. Approximately 44.6% of participants required a booster dose 18-26 years after primary vaccination. Prebooster anti-HBs titration may predict the response to booster doses. Further studies with larger groups are needed to confirm these findings.

Expanding treatment indications in chronic hepatitis B: Should we treat all patients?

Nucleos(t)ide analogues (NUCs) are first-line agents for chronic hepatitis B (CHB). Current guidelines provide recommendations for NUC initiation, yet the guidelines are complex and restrictive. Accumulating data on hepatitis B virus (HBV) replication and HBV integration suggests that there are no real quiescent disease phases in CHB, and treatment-ineligible patients in current guidelines still have substantial risks of cirrhosis and hepatocellular carcinoma. Expanding CHB treatment indications can effectively reduce the risks of liver-related complications. Furthermore, treatment indication expansion can be cost-effective, and can simplify care pathways to remove treatment barriers. Potential caveats for treatment expansion include risks of non-compliance, long-term side effects from NUCs, and poor patient acceptability. Nonetheless, these caveats are not insurmountable, and the benefits of treatment expansion outweigh the disadvantages. There is consensus among hepatologists in supporting treatment indication expansion, although expert panels have varying recommendations on treatment strategies. A treat-all approach, which involves treating all CHB patients, has also been proposed. A treat-all strategy is straightforward, and should yield the greatest benefits from a population health perspective. However, the feasibility of new treatment strategies, especially the treat-all approach, is influenced by multiple factors including local epidemiology, healthcare resource availability, and socioeconomic factors. A one-size-fits-all approach is not optimal, and treatment expansion strategies that are tailored based on local data should yield the greatest impact toward hepatitis elimination.

Association Between Elevation of Serum Alanine Aminotransferase and HBsAg Seroclearance After Nucleos(t)ide Analog Withdrawal

BACKGROUND

Alanine aminotransferase (ALT) frequently elevates in chronic hepatitis B patients stopping nucleos(t)ide analogs (NAs).

AIMS

To clarify the association between ALT elevation and HBsAg seroclearance after NA withdrawal.

METHODS

This multicenter cohort study reviewed consecutive patients discontinuing NA between 2004/04/01 and 2022/05/24. Treatment initiation and discontinuation generally followed the Asian-Pacific guidelines. Eligible patients had negative HBeAg and undetectable HBV DNA before treatment cessation, without malignancy, organ transplant or autoimmune disorders. We used competing risk analysis to estimate HBsAg seroclearance incidence and a time-dependent model to investigate post-cessation ALT elevation.

RESULTS

Among 841 patients (74.7% male; median age, 53.2 years; median treatment duration, 34.7 months), 38 patients cleared HBsAg over a median follow-up of 3.7 years, with a 10-year cumulative incidence of 12.4%. The median peak ALT level was significantly lower in patients achieving HBsAg seroclearance versus not (93 vs. 127 U/L; p < 0.001). Hepatitis flare after NA cessation (> 5 times upper limit) was inversely associated with HBsAg seroclearance in the univariable analysis (sub-distribution hazard ratio [SHR], 0.31; 95% confidence interval [CI], 0.13-0.73; p = 0.007), and the association was not significant (adjusted SHR, 0.42; 95% CI, 0.09-2.01; p = 0.28) in the multivariable analysis adjusted for pretreatment HBV DNA. Consistent results were observed in the sensitivity analyses with different ALT cutoffs and subgroup analysis adjusted for HBsAg levels at treatment cessation.

CONCLUSION

ALT elevation after NA cessation is not associated with HBsAg seroclearance following NA withdrawal, suggesting cytolytic pathways are not essential for a functional cure.

A prediction model for complications caused by portal hypertension or liver cancer in a Spanish cohort of chronic hepatitis B patients

BACKGROUND AIMS

To identify risk factors associated with liver complications in patients with chronic hepatitis B infection in an unselected cohort of hepatitis B patients in southern Spain.

METHODS

A prospective open-cohort study was conducted on 437 patients with uncomplicated chronic hepatitis B infection in two hospitals in Málaga, southern Spain. The follow-up time ranged from 0.5 to 31.5 years (mean: 13.8±9.5 years; median: 11.4 years). The aim of this study was to evaluate the occurrence of the initial liver complication during follow-up, which is defined as the emergence of liver cancer or complications resulting from portal hypertension. Survival curves were obtained using a time-to-event method through Kaplan-Meier analysis. Multivariate Cox regression was conducted to estimate the hazard ratios of risk factors associated with complications after adjusting for multiple variables. The follow-up of the patients was carried out under conditions of usual clinical practice. Based on the weighted adjustment of these factors, we developed a Hepatitis B Complication Score (HBCS) from which it was possible to identify patients with low and high risk of complications during follow-up.

RESULTS

33 out of 437 patients (7.55%) experienced liver complications, 12 (36.3%) were secondary to portal hypertension, and 21 patients (63.7%) developed liver cancer. A Multivariate Cox regression identified the following independent risk factor: Age above 45 years: HR 7.10 (2.9-17.3); low platelet count: HR 4.88 (2.1-10.9); hepatitis C coinfection: HR 4.68 (2.0-10.9); Male gender: HR 4.64 (1.5-14.2); alkaline phosphatase above 147 UI/mL: HR 4.33 (2.0-8.9); and Child score above 5 points: HR 3.83 (1.7-8.4). The Risk of Complications Score (HBCS) was developed with a high predictive capacity AUROC 0.92 (0.87-0.97).

CONCLUSION

An HBCS score greater than 3.07 points identifies patients at high risk of developing complications and with an increased risk of liver and all-cause mortality.

Usefulness of serum HBV RNA levels for predicting antiviral response to entecavir treatment in patients with chronic hepatitis B

BACKGROUND

Hepatitis B virus (HBV) RNA is an important serum biomarker of hepatic covalently closed circular DNA (cccDNA) transcriptional activity; however, its clinical characteristics remain unclear. This study evaluated the clinical utility of HBV RNA levels in patients with chronic hepatitis B (CHB).

METHODS

We studied 87 CHB patients with serum HBV DNA levels ≥ 5.0 log IU/mL who initiated entecavir (ETV) treatment between 2000 and 2018. Serum HBV RNA levels were measured at three-time points: before ETV treatment, at 12 weeks, and at 48 weeks after starting ETV treatment. Clinical markers associated with the antiviral effects of ETV treatment were analyzed.

RESULTS

Serum HBV RNA levels decreased in both HBeAg-positive and -negative patients during the observation period. In HBeAg-positive patients, multivariable analysis showed that lower HBV RNA levels at 48 weeks of ETV treatment were independently associated with HBeAg seroconversion. Additionally, lower baseline HBV RNA levels significantly predicted virologic response in those patients. In contrast, among HBeAg-negative patients, lower HBV core-related antigen (HBcrAg) levels and the FIB-4 index were independently associated with virologic response. In HBeAg-positive patients, those with higher baseline HBV RNA levels showed a more significant reduction in hepatitis B surface antigen levels.

CONCLUSION

Serum HBV RNA levels predicted HBeAg seroconversion and early HBV DNA reduction in HBeAg-positive patients, while HBcrAg was significantly associated with virologic response in HBeAg-negative patients. These findings highlight the different predictive roles of HBV RNA and HBcrAg based on HBeAg status, which may provide individualized treatment strategies.

Efficacy and Safety of Tenofovir Amibufenamide and Tenofovir Alafenamide for First-Time HBV-Related Decompensated Cirrhosis

Clinical studies of tenofovir amibufenamide (TMF) and tenofovir alafenamide (TAF) treatment in patients with HBV-related decompensated cirrhosis (HBV-DC) are limited. This study evaluated the efficacy and safety of TMF versus TAF in naive-treated patients with first-time HBV-DC. Based on the antiviral drug used, patients were categorised into the TMF group and the TAF group. Virological and serological responses, hepatic and renal functions and blood lipid changes in both groups were evaluated during 48 weeks of treatment. A total of 98 patients were enrolled, 45 in the TMF group and 53 in the TAF group. At 48 weeks of treatment, the proportions of patients who achieved complete virological response (CVR) were 85.7% and 90.7%, respectively (p = 0.791). Improvement of at least 2 points in Child-Turcotte-Pugh scores was observed in 64.3% versus 79.1% (p = 0.169) of the patients. There were no significant changes in serum creatinine, estimated glomerular filtration rate or total cholesterol from baseline to week 48 between the two groups. Cystatin C remained stable in the TMF group but increased over time in the TAF group (p < 0.001). Low-density lipoprotein cholesterol remained stable in the TMF group but increased significantly in the TAF group at week 48 (p = 0.015). These results suggest that both TMF and TAF can rapidly suppress HBV replication, improve hepatic function and have no negative effects on renal function among patients with HBV-DC. Regarding lipid metabolism, both showed a better safety, while regular monitoring of blood lipid levels is recommended.

Diversity and inclusion in chronic hepatitis B randomised controlled trials: A systematic meta-epidemiological review

Background & Aims

Chronic hepatitis B (CHB) affects global populations unequally, with variable prevalence and pathophysiology. Clinical trials must balance efficiency with adequate representation of the populations most likely to benefit from the interventions they test. We aimed to investigate diversity and inclusion in CHB trials.

Methods

We performed a meta-epidemiological study of randomised controlled trials recruiting people with CHB published in MEDLINE and Embase, January 2010 to July 2023. We extracted participant age, sex, country of recruitment, race and ethnicity, and hepatitis B genotype. We calculated proportions of trials reporting participant demographics and results by demographics (transparency). We compared participants proportionately to global populations affected by CHB of different demographics (representation), and examined demographic-based trial exclusion criteria.

Results

Among 287 trials (81.9% single-country, 18.1% multinational) with 57,503 participants (median size: 102, IQR: 60-185), 97.9% tested drug interventions. Most trials reported participants' age distribution (285, 99.3%) and sex (278, 96.9%). However, only 37.3% (107) trials reported race and ethnicity, 84 (29.3%) reported genotype, and, among multinational trials, only 19 (36.5%) reported recruitment numbers by country. Less than 3% trials reported demography-stratified results. Female sex was under-represented (42.0% people with CHB, 28.7% trial participants). Geographic disparities between those affected by CHB and trial participation were marked for Africa (31.0% vs. 0.01%; under-representation), and Americas or Europe (5.7% vs. 14.0%; over-representation). Many trials had exclusion criteria based on age (71.4% children, 41.5% older adults) or sex-related (157, 54.7%), mostly excluding women who were pregnant, breastfeeding, or of reproduction potential.

Conclusions

Clinical trials for CHB are not inclusive of women and people in Africa. Researchers, funders, and publishers should actively consider diversity and inclusion of trials.

Impact and implications

Clinical trials must balance the need to recruit homogenous participants to efficiently measure an intervention's effectiveness, with the need to produce evidence that can be applied to the whole population affected by a disease. We found chronic hepatitis B (CHB) clinical trials often failed to report basic demographic characteristics of participants, and had under-representation of women and people living in Africa. Given varied disease pathophysiology and treatment needs among different groups, this suggest a mismatch of evidence generation compared with the populations needing treatment, whereby the benefits and harms of different interventions across populations are not being adequately studied. We suggest relevant stakeholders, including researchers, funders, and publishers of CHB clinical trials, should actively recruit under-represented populations, target interventions to those most at need, and either consider demographic factors in results reporting and analysis, or make data easily available for interrogation.

Low-Level Viremia Impairs Efficacy of Immune Checkpoint Inhibitors in Unresectable Hepatocellular Carcinoma

BACKGROUND AND AIMS

The impact of low-level viremia(LLV) on the efficacy of immune checkpoint inhibitors (ICIs) in unresectable hepatocellular carcinoma(uHCC) patients remains unclear. This study aims to investigate the effect of LLV on the outcomes of ICIs-based therapy in patients with uHCC.

METHODS

In this multicenter retrospective study, we included patients with uHCC who received ICIs-based therapy at four centres between January 2019 and December 2022. All patients were positive for HBsAg and were on nucleos(t)ide analogues (NAs) antiviral therapy. Propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) were used to balance baseline characteristics between the LLV and maintained virological response (MVR) groups. Proteomic analysis was performed on a subset of patients to identify differential protein expression.

RESULTS

A total of 329 patients (mean age 56 years; 92.4% male; 70.8% BCLC stage C) were included, with 170 patients in the LLV group and 159 in the MVR group. The objective response rate (ORR) was significantly lower in the LLV group compared to the MVR group (21.2% vs. 36.5%, p = 0.002), as was the disease control rate (DCR) (78.8% vs. 92.5%, p < 0.001). Median progression-free survival (mPFS) was shorter in the LLV group (7.6 vs. 12.6 months, p < 0.001), as was median overall survival (mOS) (22.8 vs. 40.0 months, p < 0.001). These differences remained consistent after PSM and IPTW adjustments. Multivariate analysis identified LLV as the only independent risk factor for overall survival (hazard ratio [HR] 0.522, 95% CI 0.348-0.781; p = 0.002). Proteomic analysis revealed significant differences in the expression of Flt3L, SLAMF1 and FGF-5 proteins between the LLV and MVR groups.

CONCLUSION

LLV is associated with poorer responses to ICIs-based therapy and reduced survival in patients with HBV-related uHCC.

Prediction of intrahepatic covalently closed circular DNA levels in patients with resolved hepatitis B virus infection: Impact of serum antibody to hepatitis B core antigen titers

AIM

The correlation between intrahepatic covalently closed circular DNA (cccDNA) levels and serum hepatitis B virus (HBV) markers in patients with resolved HBV infection (hepatitis B surface antigen [HBsAg]-negative and antibody to hepatitis B core antigen [anti-HBc]-positive) is unclear. We therefore examined the utility of anti-HBc titers as a surrogate marker of intrahepatic cccDNA levels in patients with resolved HBV infections.

METHODS

Among 1005 patients who underwent hepatectomy between 2010 and 2018, a retrospective review was performed in 114 patients (76 with resolved HBV infection and 38 HBsAg-positive) with frozen specimens of the background liver. Clinical, biochemical, and virological data, including intrahepatic cccDNA levels, were retrospectively evaluated. Intrahepatic cccDNA levels were measured using droplet digital polymerase chain reaction.

RESULTS

Intrahepatic cccDNA levels positively correlated with serum HBsAg levels (r = 0.609, p < 0.001) and anti-HBc titers (r = 0.542, p < 0.001). An intrahepatic cccDNA level of 22.2 copies/μg was the optimal cut-off for HBsAg positivity, with a sensitivity of 86.8% and specificity of 89.5%. Of the 76 cases with resolved HBV infection, 8 had high levels of intrahepatic cccDNA (≥22.2 copies/μg). Multivariate analyses showed that anti-HBc ≥ 11.0 sample/cut-off (S/CO) was an independent risk factor for high intrahepatic cccDNA levels (odds ratio, 12.6; 95% confidence interval, 2.4-66.156; P = 0.003).

CONCLUSIONS

Anti-HBc titers were positively correlated with intrahepatic cccDNA levels. Even in patients with resolved HBV infection, anti-HBc ≥ 11.0 S/CO was considered to indicate high intrahepatic cccDNA levels, comparable to those in HBsAg-positive cases. In this group, careful monitoring is required during immunosuppressive therapy to prevent HBV reactivation.

Accuracy of International Guidelines in Identifying Normal Liver Histology in Chinese Patients With HBeAg-Positive Chronic HBV Infection

We evaluated the diagnostic accuracy of various international guideline criteria for identifying HBeAg-positive chronic HBV infection patients with no significant liver disease. A total of 1108 HBeAg-positive CHB patients were retrospectively enrolled. The guidelines assessed included those from the European Association for the Study of the Liver (EASL) 2017, the American Association for the Study of the Liver Disease (AASLD) 2018, the Asian Pacific Association for the Study of the Liver (APASL) 2015 and the Chinese Society of Hepatology (CSH) 2022. The CSH criteria demonstrated a higher proportion of patients with G0-1 and S0-1 (82.9%) compared to the EASL (75.9%), AASLD (75.3%) and APASL groups (58.8%). Additionally, the CSH criteria exhibited a significantly higher predictive value (AUC 0.782, 95% CI 0.754-0.809) than the EASL (AUC 0.765, 95% CI 0.737-0.793), AASLD (AUC 0.749, 95% CI 0.720-0.778) and APASL (AUC 0.720, 95% CI 0.690-0.750) criteria for identifying G0-1 and S0-1. Adding quantitative HBsAg levels (> 104 IU/mL) to the EASL, AASLD and APASL criteria improved diagnostic performance. Consequently, the CSH guideline thresholds showed higher accuracy in identifying Chinese HBeAg-positive patients with no significant liver disease compared to EASL, AASLD and APASL criteria, emphasising the importance of considering quantitative HBsAg in the evaluation of HBeAg-positive chronic HBV infection.

A Machine Learning Model to Predict De Novo Hepatocellular Carcinoma Beyond Year 5 of Antiviral Therapy in Patients With Chronic Hepatitis B

BACKGROUND AND AIMS

This study aims to develop and validate a machine learning (ML) model predicting hepatocellular carcinoma (HCC) in chronic hepatitis B (CHB) patients after the first 5 years of entecavir (ETV) or tenofovir (TFV) therapy.

METHODS

CHB patients treated with ETV/TFV for > 5 years and not diagnosed with HCC during the first 5 years of therapy were selected from two hospitals. We used 36 variables, including baseline characteristics (age, sex, cirrhosis, and type of antiviral agent) and laboratory values (at baseline, at 5 years, and changes between 5 years) for model development. Five machine learning algorithms were applied to the training dataset and internally validated using a test dataset. External validation was performed.

RESULTS

In years 5-15, a total of 279/5908 (4.7%) and 25/562 (4.5%) patients developed HCC in the derivation and external validation cohorts, respectively. In the training dataset (n = 4726), logistic regression showed the highest area under the receiver operating curve (AUC) of 0.803 and a balanced accuracy of 0.735, outperforming other ML algorithms. An ensemble model combining logistic regression and random forest performed best (AUC, 0.811 and balanced accuracy, 0.754). The results from the test dataset (n = 1182) verified the good performance of the ensemble model (AUC, 0.784 and balanced accuracy, 0.712). External validation confirmed the predictive accuracy of our ensemble model (AUC, 0.862 and balanced accuracy, 0.771). A web-based calculator was developed (http://ai-wm.khu.ac.kr/HCC/).

CONCLUSIONS

The proposed ML model excellently predicted HCC risk beyond year 5 of ETV/TFV therapy and, therefore, could facilitate individualised HCC surveillance based on risk stratification.

Impact of Maternal Hepatitis B Virus Infection on Congenital Heart Disease Risk in Offspring: A National Cohort Study

Maternal hepatitis B virus (HBV) infection influence both maternal and fetal health. Recent studies reported increased congenital anomalies in offspring of HBV-infected mothers. This study investigated whether maternal HBV infection was associated with higher risk of congenital heart disease (CHD) in children. With the Korean National Health Insurance Service (K-NHIS) database, this retrospective cohort study included live births from 2005 to 2019, born to women under 40. Propensity score matching with a 1:3 ratio was conducted to compare HBV-infected mother's children with HBV-uninfected mother's children while adjusting for various maternal and pregnancy-related factors. Logistic regression models were used to estimate the risk. Of 2,673,059 eligible participants, 263,904 children were born to HBV-infected mothers. Risk estimation in this group showed a modestly increased risk of CHD (OR = 1.05, 95% CI = 1.02, 1.09). Notably, when pregnant mothers were treated with antiviral medication, there was an indication of reduced CHD risk, although this result was not statistically significant. The highest risk of CHD was observed in children who were themselves infected with HBV. The study indicates an association between maternal HBV infection and an increased CHD risk in offspring. The findings suggest the need to re-evaluate the timing of antiviral treatment during pregnancy to align more closely with early stages of fetal cardiac development. Further research is needed to understand the biological mechanisms of this association and to redefine clinical guidelines for managing HBV infection in pregnancy.

Early antiviral treatment with tenofovir alafenamide to prevent serious clinical adverse events in adults with chronic hepatitis B and moderate or high viraemia (ATTENTION): interim results from a randomised controlled trial

BACKGROUND

Current guidelines for chronic hepatitis B recommend antiviral therapy for individuals with non-cirrhotic chronic hepatitis B only if they have significant liver fibrosis or elevated alanine aminotransferase (ALT) concentrations. We aimed to assess the efficacy of early antiviral treatment in preventing serious liver-related adverse events in individuals with non-cirrhotic chronic hepatitis B and moderate or high viraemia but normal or mildly elevated ALT concentrations.

METHODS

ATTENTION is an ongoing randomised controlled trial being conducted at 22 centres in South Korea and Taiwan. Adults aged 40-80 years with non-cirrhotic chronic hepatitis B and serum hepatitis B virus (HBV) DNA concentrations between 4 log10 IU/mL and 8 log10 IU/mL, and ALT concentrations lower than 70 U/L for males and 50 U/L for females were recruited and randomly assigned (1:1) to receive either oral tenofovir alafenamide (25 mg daily) or no antiviral treatment (observation). The primary endpoint was a composite of hepatocellular carcinoma, hepatic decompensation (eg, development of portal hypertensive complications including ascites, gastro-oesophageal varices, or Child-Pugh score of ≥7), liver transplantation, or death from any cause, analysed in the intention-to-treat population. The safety population comprised all randomly assigned participants who received at least one dose of the study treatment. This interim analysis was prespecified at 4 years after enrolment of the first participant. This study is registered with ClinicalTrials.gov, NCT03753074.

FINDINGS

Between Feb 8, 2019 and Oct 17, 2023 (the cutoff date for the first interim analysis), 798 individuals were screened and 734 were randomly assigned (369 to tenofovir alafenamide and 365 to observation). At a median follow-up of 17·7 months (IQR 8·3-24·4), the primary endpoint occurred in 11 participants: two in the tenofovir alafenamide group (both hepatocellular carcinoma) and nine in the observation group (seven hepatocellular carcinoma, one hepatic decompensation, and one death), corresponding to an incidence rate of 0·33 per 100 person-years in the tenofovir alafenamide group and 1·57 per 100 person-years in the observation group (hazard ratio 0·21 [97·5% CI 0·04-1·20]; p=0·027). The difference between the two groups did not surpass the prespecified boundaries required to stop the trial early. Serious adverse events, excluding primary endpoints, were reported in 23 (6%) participants in the tenofovir alafenamide group and 24 (7%) in the observation group.

INTERPRETATION

The results of this interim analysis suggest that early treatment with tenofovir alafenamide reduces the risk of liver-related serious adverse events compared with observation in adults with non-cirrhotic chronic hepatitis B and moderate or high viraemia but normal or mildly elevated ALT concentrations. Although these findings await confirmation in planned future analyses, they suggest that existing guidelines could be expanded to allow early antiviral therapy in patients with a moderate or high HBV viral load, irrespective of ALT concentrations.

FUNDING

Government of South Korea and Gilead Sciences.

Long-term virological and clinical evaluation of chronic hepatitis B patients under nucleos(t)ide analogues therapy

INTRODUCTION AND OBJECTIVES

Identifying hepatitis B virus (HBV) patients eligible for safe nucleos(t)ide analogues (NAs) discontinuation remains challenging. Discrepant data on combined HBV DNA and quantitative HBV surface antigen (qHBsAg) assessments are available. This study aimed to identify potential predictors for safe treatment discontinuation by evaluating clinical/virological outcomes in patients on long-term NA therapy.

PATIENTS AND METHODS

A retrospective cohort of 139 chronic hepatitis B (CHB) patients - who consecutively started Entecavir or Tenofovir from 2007 to 2011 - was evaluated. The study population was selected based on anti-HBe positivity, absence of prior antiviral treatment, absence of non-HBV-related liver diseases or hepatocellular carcinoma (HCC), and long-term clinical/ultrasonographic/laboratory evaluations post-NA initiation. Serum samples collected before starting NA (T0) and over ten years (T1-T10) were tested for HBV DNA and qHBsAg.

RESULTS

Twenty-two/139 (15.8 %) CHB patients (12 chronic hepatitis, 10 cirrhosis) met the inclusion criteria. All patients showed a significant decrease in liver stiffness values in the ten years of follow-up (p = 0.001), and no hepatic decompensation occurred. Three/22 (13.6 %) patients developed HCC. Ten/22 patients (45.5 %; group-A) had fluctuating HBV DNA, while other 10/22 (45.5 %; group-B) showed undetectable HBV DNA for 5-9 years with more significant qHBsAg decline (p = 0.04) than group-A. Two/22 (9.1 %) patients showed a critical qHBsAg decline up to seroconversion together with undetectable HBV DNA.

CONCLUSIONS

Persistent undetectable HBV DNA levels correlate with qHBsAg reduction and the potential HBsAg seroclearance, suggesting that long-term HBV DNA monitoring in NA-treated CHB patients might help identify candidates for treatment discontinuation.

British Society of Gastroenterology guidelines for diagnosis and management of autoimmune hepatitis

Autoimmune hepatitis (AIH) is a chronic inflammatory liver disease which, if untreated, often leads to cirrhosis, liver failure and death. The last British Society of Gastroenterology (BSG) guideline for the management of AIH was published in 2011. Since then, our understanding of AIH has advanced in many areas. This update to the previous guideline was commissioned by the BSG and developed by a multidisciplinary group. The aim of this guideline is to review and summarise the current evidence, in order to inform and guide diagnosis and management of patients with AIH and its variant syndromes. The main focus is on AIH in adults, but the guidelines should also be relevant to older children and adolescents.

Disparities in Social Vulnerability and Premature Mortality among Decedents with Hepatitis B, United States, 2010-2019

BACKGROUND

Current US hepatitis B mortality rates remain three times higher than the national target. Mortality reduction will depend on addressing hepatitis B disparities influenced by social determinants of health.

OBJECTIVES

This study aims to describe characteristics of hepatitis B-listed decedents, which included US birthplace status and county social vulnerability attributes and quantify premature mortality.

METHODS

We conducted a cross-sectional analysis of 17,483 hepatitis B-listed decedents using the 2010-2019 US Multiple-Cause-of-Death data merged with the county-level Social Vulnerability Index (SVI). Outcomes included the distribution of decedents according to US birthplace status and residence in higher versus lower death burden counties by sociodemographic characteristics, years of potential life lost (YPLL), and SVI quartiles.

RESULTS

Most hepatitis B-listed decedents were US-born, male, and born during 1945-1965. Median YPLL was 17.2; 90.0% died prematurely. US-born decedents were more frequently White, non-college graduates, unmarried, and had resided in a county with < 500,000 people; non-US-born decedents were more frequently Asian/Pacific Islander, college graduates, married, and had resided in a county with ≥ 1 million people. Higher death burden (≥ 20) counties were principally located in coastal states. US-born decedents more frequently resided in counties in the highest SVI quartile for "Household Characteristics" and "Uninsured," whereas non-US-born decedents more frequently resided in counties in the highest SVI quartile for "Racial/Ethnic Minority Status" and "Housing Type/Transportation."

CONCLUSION

This analysis found substantial premature hepatitis B mortality and residence in counties ranked high in social vulnerability. Successful interventions should be tailored to disproportionately affected populations and the social vulnerability features of their geographic areas.

Bulevirtide Monotherapy Is Safe and Well Tolerated in Chronic Hepatitis Delta: An Integrated Safety Analysis of Bulevirtide Clinical Trials at Week 48

BACKGROUND AND AIMS

The safety and tolerability of bulevirtide (BLV), a novel entry inhibitor of hepatitis delta virus, were evaluated in an integrated analysis of clinical trial results from patients with chronic hepatitis delta (CHD).

METHODS

Week 48 on-treatment clinical and laboratory results from two Phase 2 trials (MYR203 [NCT02888106] and MYR204 [NCT03852433]) and one Phase 3 trial (MYR301 [NCT03852719]) were pooled (N = 269). Patients were grouped as follows: BLV 2 mg (n = 64), BLV 10 mg (n = 115), pegylated interferon-alfa (n = 39) and control (n = 51). The control group consisted of patients assigned to the delayed treatment group in Study MYR301.

RESULTS

Adverse events (AEs) that occurred more frequently with BLV 2 mg and BLV 10 mg versus control included increased total bile acid levels (20% and 17% vs. 0%), injection-site reactions (16% and 20% vs. 0%), headache (16% and 17% vs. 0%), pruritus (11% and 10% vs. 0%) and eosinophilia (9% and 4% vs. 0%). Increases in total bile acid levels were observed with BLV without clear correlation with AEs, such as pruritus, eosinophilia or vitamin D deficiency. Grade 3 or 4 study drug-related AEs occurred in a higher proportion of patients receiving pegylated interferon-alfa (51%) than with BLV 2 or 10 mg (3% and 4%, respectively). There were no serious AEs related to BLV, and no patients discontinued BLV due to an AE. Neither hepatic decompensation nor death occurred.

CONCLUSIONS

BLV monotherapy was safe and well tolerated through 48 weeks of treatment in patients with CHD.

TRIAL REGISTRATION

NCT02888106, NCT03852433 and NCT03852719.

Effectiveness and Safety of Tenofovir Amibufenamide in the Treatment of Chronic Hepatitis B: A Real-world, Multicenter Study

Background and Aims

Chronic hepatitis B (CHB) remains a significant global health challenge, and effective antiviral therapies are essential for long-term management. This study aimed to evaluate the real-world effectiveness and safety of tenofovir amibufenamide (TMF) in a cohort of patients with chronic hepatitis B (CHB).

Methods

In this multicenter, prospective, real-world cohort study, 194 CHB patients were recruited from four hospitals between August 2021 and August 2022. Patients were divided into treatment-naïve (TN, n = 123) and treatment-experienced (TE, n = 71) groups. The TN group was further subdivided into TMF (n = 63) and tenofovir disoproxil fumarate (TDF, n = 60) subgroups. In the TE group, patients transitioned from prior antiviral therapies (entecavir or TDF) to TMF after meeting criteria for poor virological response or safety concerns. Treatment response was evaluated in terms of virological effectiveness and alanine transaminase normalization rates. Virological response (VR), ALT normalization rates, renal function markers, and lipid profiles were monitored.

Results

In the TN cohort, VR rates at 24 and 48 weeks were 42.86% and 90.48% for TMF, and 60.00% and 83.33% for TDF. ALT normalization rates at 24 and 48 weeks for TMF were 56.82% and 70.45% (according to AASLD 2018 standards). In the TE group, VR rates at 24 and 48 weeks were 83.1% and 91.55%, respectively. ALT normalization rates were 86.67% and 93.33% (local standards), and 66.67% and 76.67% (AASLD 2018 standards) (z = -2.822, P = 0.005). Additionally, TMF showed improved renal safety over TDF, with no significant differences in lipid concentrations.

Conclusions

TMF is comparable to TDF in terms of CHB treatment effectiveness, with better renal safety and no impact on lipid levels. In TE patients, transitioning to TMF therapy does not affect antiviral treatment outcomes.