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

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.

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.

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).

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.

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.

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.

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 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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Liver histological study of patients with chronic hepatitis B virus infection in the grey zone

BACKGROUND AND AIM

The natural history of chronic hepatitis B virus (HBV) infection is usually divided into four phases: immune tolerant (IT), immune active (IA), immune carrier (IC), and immune reactive (IR). Many patients still cannot be classified into the four phases, called "Grey Zone (GZ)". This study aimed to analyze the liver histological features of the GZ patients to guide antiviral therapy.

METHODS

We retrospectively analyzed the 1454 patients with chronic HBV infection who underwent liver biopsy. GZ patients with identical serum hepatitis Be antigen (HBeAg) and alanine aminotransferase (ALT) levels as those in the IT, IA, IC, and IR phases were categorized into the IT-GZ, IA-GZ-1, IA-GZ-2, IC-GZ, and IR-GZ groups, respectively. We analyzed and compared the histological distribution of liver in these patients. We evaluated independent influencing factors for significant liver histological changes (SLHC) in patients in the GZ subgroups.

RESULTS

Among the 1454 patients, 690(47.5%) patients in GZ. Among the 690 patients of the GZ, 322(46.7%) patients for whom histological examinations indicated SLHC. The proportion of SLHC within the GZ subgroups was as follows: IT-GZ (50.5%), IA-GZ-1 (75.0%), IA-GZ-2 (48.4%), IC-GZ (32.1%), and IR-GZ (59.6%). In the IT-GZ group, the proportion of patients aged ≤ 30 years with SLHC was 47.1%, and in the IC-GZ group, this proportion was 42.1%.

CONCLUSIONS

46.7% of GZ patients had significant liver histological changes. For HBeAg-negative patients with ALT ≤ 40U/L, HBV DNA ≥ 2000IU/mL, and an age of ≤ 30 years old, antiviral therapy was recommended; if they expressed concern, a liver biopsy was suggested.

Nucleos(t)ide analogs continuation is not associated with a lower risk of HBsAg seroreversion following PEG-IFN-induced HBsAg loss

BACKGROUND/AIMS

It is unclear whether nucleos(t)ide analogs (NUCs) continuation provides clinical benefits following HBsAg seroclearance with pegylated interferon (PEG-IFN)-based therapy. This study aims to investigate the role of NUCs continuation in HBsAg seroreversion.

METHODS

Patients who experienced serum HBsAg loss after PEG-IFN-based therapy were enrolled and followed up for 96 weeks. Propensity score matching (PSM) was performed using a 1:1 ratio to adjust for the associated factors. A multivariate logistic regression analysis was used to determine the factors associated with HBsAg seroreversion.

RESULTS

In total, 220 patients with HBsAg seroclearance were divided into NUCs (n = 54) and non-NUCs (n = 166) consolidation therapy groups. At week 96, the HBsAg seroreversion (12/54 vs. 31/166, P = 0.709) and virological relapse (2/54 vs. 10/166, P = 0.759) rates were similar in the NUCs and non-NUCs groups. After PSM, HBsAg seroreversion (12/53 vs. 13/53; P = 1.000) and virological relapse (2/53 vs. 4/53; P = 0.674) rates were not significantly different between the two groups. Serum hepatitis B surface antibody titer (odds ratio, 0.388; 95% confidence interval, 0.245-0.616; P < 0.001) was found to be associated with HBsAg seroreversion, while NUCs continuation was not related to HBsAg seroreversion.

CONCLUSIONS

NUCs continuation is not associated with a lower risk of HBsAg seroreversion in patients with serum HBsAg loss following PEG-IFN-based therapy.

Racial Differences in Liver Fibrosis Burden

BACKGROUND & AIMS

Liver histology is the classic method for staging the severity of liver fibrosis, which in turn is an important predictor of clinical outcome. Here, we have hypothesized that the susceptibility to develop fibrosis varies among racial groups.

METHODS

We examined the histology of all patients over 18 years of age who underwent liver biopsy at the Medical University of South Carolina from 1/1/2013 to 7/1/2021. Patients with malignancy, liver metastases, or missing data were excluded. Fibrosis was quantified using the Batts-Ludwig system (F0 = no fibrosis to F4 = histological cirrhosis). Racial groups were propensity matched based on age, gender, diabetes, alcohol consumption, and CDC/ATSDR Social Vulnerability Index Themes to mitigate the risk of selection bias.

RESULTS

We identified 1101 patients with liver biopsy histological fibrosis scores. The cohort included 23% Black patients. After propensity matching, Black patients were significantly more likely to have Hepatitis C (73/228 (32%) vs 45/228 (20%), p < 0.001) and autoimmune hepatitis (34/228 (15%) vs 6/228 (3%), p < 0.001) than White patients, while White patients were significantly more likely to have metabolic dysfunction associated steatotic liver disease (71/228 (31%) vs 18/228 (8%), p < 0.001). White patients were significantly more likely to have cirrhosis than Black patients (White - 89/228 (39%) vs Black - 68/228 (30%), p < 0.05).

CONCLUSION

White patients had a greater overall burden of advanced fibrosis (F4/cirrhosis) than Black patients, independent of etiology. The data suggest that fibrosis risk and/or progression may be worse in White than Black patients.