Metabolic Dysfunction-Associated Steatotic Liver Disease Facilitates Hepatitis B Surface Antigen Seroclearance and Seroconversion

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

BACKGROUND & AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND/OBJECTIVE

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL TRIAL REGISTRATION

NCT06041022.

Metabolic dysfunction-associated steatotic liver disease and its associated health risks

This article synthesizes the current knowledge on the epidemiology of metabolic dysfunction-associated steatotic liver disease (MASLD), its associated risks, and its genetic determinants. The findings presented in this article can be used to develop clinical strategies to reduce MASLD's growing global burden. MASLD has become a major global health concern due to increasing rates of obesity, sedentary lifestyles, and metabolic disorders. MASLD is a leading cause of end-stage liver diseases, including cirrhosis and hepatocellular carcinoma (HCC), and MASLD also significantly increases the risk of cardiovascular disease (CVD), thereby exerting dual effects on liver and cardiovascular health. MASLD was once referred to as nonalcoholic fatty liver disease, and this change in nomenclature reflects a growing focus on its metabolic underpinnings, facilitating the more precise diagnosis and clinical management of this disease. Epidemiological studies have demonstrated that the prevalence of MASLD is increasing worldwide, although the prevalence varies across regions and populations. Noninvasive diagnostic tools such as ultrasound and fatty liver indices along with biomarkers such as alanine aminotransferase (ALT) are crucial for early detection and risk stratification. Genetic research has identified key gene variants, including PNPLA3 (rs738409) and TM6SF2 (rs58542926), that influence MASLD susceptibility and progression, and these findings have created opportunities for improving precision medicine with respect to treating MASLD. Research has revealed an association between MASLD and major adverse cardiovascular events and increased mortality, which highlights the importance of integrating cardiovascular risk management into treatment strategies for MASLD. Future research should focus on advancing noninvasive diagnostics, leveraging genetic insights to provide tailored care, and implementing population-specific interventions to address regional variations.

Combining therapeutic agents to target the immune systems of hepatitis B patients: what do we need to consider?

INTRODUCTION

Chronic hepatitis B (CHB) remains a major global health challenge, with functional cure achieved in only a small subset of patients. Current oral antiviral agents effectively suppress viral replication but fail to eliminate the hepatitis B virus (HBV). Recent advances in immunomodulatory therapies offer new hope for improving functional cure rates.

AREAS COVERED

This special report discusses the latest therapeutic strategies targeting immune responses in CHB. We list the mechanisms of immune evasion in HBV infection and highlight emerging immunomodulatory agents. Key findings from recent clinical trials and critical considerations are summarized to provide an overview of ongoing efforts and future direction to achieve functional cure.

EXPERT OPINION

While combination therapies hold promise, their real-world feasibility depends on patient selection, combination regimens, costs, and global accessibility. A successful HBV cure strategy must integrate scientific innovation with public health policies to ensure equitable access to effective treatments. Future research should identify key immune mechanisms, optimize combination regimens, and improve global treatment infrastructure.

Cardiometabolic Comorbidities in Patients With Chronic Hepatitis B and Impact on Incidence of Liver Complications. A Danish Nationwide Cohort Study

Purpose

To evaluate liver complications in patients with chronic hepatitis B, both with and without cardiometabolic comorbidities, and to compare the incidence of cardiometabolic comorbidities in these patients with that of the general population.

Study Population and Methods

This nationwide registry-based cohort study included data from 2002-2020. In the primary analysis, we used multivariate Poisson regression to estimate the incidence rate and incidence rate ratio of liver complications in patients with chronic hepatitis B, stratified by the presence of cardiometabolic comorbidities. In the secondary analysis, we compared the incidence rate of developing cardiometabolic comorbidities in patients with chronic hepatitis B to those of the general population. Both analyses were adjusted for sex, age, and country of origin, while the primary analysis was additionally adjusted for time since cardiometabolic comorbidity diagnosis and calendar year.

Results

The primary analysis included 4731 patients with chronic hepatitis B, of whom 532 (11%) had at least one cardiometabolic comorbidity. The unadjusted overall incidence rate of liver complications in patients with cardiometabolic comorbidities was 1.0 per 100 person-years (95% confidence intervals: 0.84-1.30) compared to 0.4 per 100 person-years (95% confidence intervals: 0.30-0.42) in those without. The incidence rate ratio for liver complications was highest in the first year following the diagnosis of cardiometabolic comorbidity. The incidence rate ratio for developing cardiometabolic comorbidities in the chronic hepatitis B cohort compared to the general population, was 1.10 (95% confidence intervals: 1.02-1.19). Sensitivity analyses revealed a higher incidence rate ratio for type 2 diabetes and hypertension but a lower incidence rate ratio for hypercholesterolemia.

Conclusion

Patients with chronic hepatitis B and cardiometabolic comorbidities exhibit a higher incidence of liver complications, particularly in the first year following comorbidity diagnosis compared to those without comorbidities. Furthermore, patients with chronic hepatitis B have a higher incidence of cardiometabolic comorbidities than the general population.

Plasma Adiponectin Levels in Relation to Chronic Hepatitis B Infection Progression to Liver Cancer Milestones: A Prospective Study

Introduction

Our previous nested-case-control study demonstrated elevated adiponectin increased liver cirrhosis and HCC risk in HBV carriers. We extended the analysis to the whole REVEAL-HBV cohort to prospectively evaluate whether adiponectin directly affected end-stage liver diseases, or through affecting HBV progression.

Methods

Baseline plasma adiponectin was determined to investigate the association between adiponectin and subsequent HBeAg, HBsAg, and HBV DNA seroclearance, and the development of cirrhosis, HCC and liver-related death. Whether HBV characteristics modify the adiponectin-milestones associations was also examined.

Results

Among 3,931 HBsAg(+)/anti-HCV(-) REVEAL-HBV participants, 3,684 had sufficient biosamples left for adiponectin assay. Elevated adiponectin was associated with a higher chance of HBeAg-seropositive, high HBV viral load (≥2 × 105 IU/mL) and high HBsAg titers (≥1,000 IU/mL) in a dose-response manner (OR = 2.25, 95% CI: 1.55-3.28; OR = 2.11, 95% CI: 1.47-3.04; and OR = 1.92, 95% CI: 1.47-2.52 for Q5 vs. Q1, respectively). Those with the highest quintile had a lower chance of achieving HBeAg (HR = 0.48, 95% CI: 0.27-0.85), HBsAg (HR = 0.69, 95% CI: 0.49-0.97), and HBV DNA seroclearance (HR = 0.63, 95% CI: 0.43-0.90) and a higher chance of developing liver cirrhosis (HR = 2.88, 95% CI: 1.98-4.20, HCC (HR = 2.38, 95% CI: 1.52-3.73), and died from liver-related causes (HR = 2.32, 95% CI: 1.51-3.54). HBV genotype significantly modified the adiponectin-HCC (Pinteraction = 0.005) and adiponectin-liver death associations (Pinteraction = 0.0157), with higher risk among genotype C.

Conclusion

Elevated adiponectin is consistently associated with all important chronic HBV infection milestones toward progression to liver cancer. The exact mechanism of how adiponectin mediates HBV infection toward carcinogenesis remains unclear and warrants further investigation. Disentangling this may help us in finding new HBV treatment target, biomarker in HBV surveillance to identify high-risk patients, or even cancer prevention.

Association of concomitant MASLD and hepatitis B virus with clinical prognosis in hepatocellular carcinoma after curative resection

The term "metabolic dysfunction-associated steatotic liver disease" (MASLD) was introduced to replace the term "nonalcoholic fatty liver disease". The prevalence of MASLD is increasing worldwide. The prevalence of concomitant MASLD and hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC) is also increasing. This study explored the effect of the coexistence of MASLD and HBV on clinicopathological features and long-term clinical prognoses in patients with MASLD-related and/or HBV-related HCC after curative hepatectomy. The study retrospectively collected the data of 653 patients with HCC who had undergone curative hepatectomy between 2011 and 2022. We assessed the association of histologically confirmed MASLD with HCC recurrence and mortality. Of 653 patients, 320 (49.0%), 103 (15.8%), and 230 (35.2%) had concomitant MASLD and HBV, MASLD only, and HBV only, respectively. The median follow-up period was 5.1 years. Patients with concomitant MASLD and HBV were at a significantly increased risk of HCC recurrence (P = 0.013 and P = 0.041) and mortality (P = 0.044 and P = 0.026) than those with MASLD or HBV alone. In multivariable analyses, concomitant MASLD and HBV, male sex, body mass index < 23, absence of antiviral therapy, and tumor size ≥ 5 cm were significantly associated with increased HCC recurrence. Concomitant MASLD and HBV, male sex, type 2 diabetes mellitus, serum aspartate aminotransferase ≥ 40 U/L, tumor size ≥ 5 cm, tumor cell differentiation II-III, microvascular invasion, lymph node invasion, and tumor recurrence were significantly associated with increased mortality. In conclusion, patients with concomitant MASLD and HBV are at a significantly greater risk of HCC recurrence and mortality after curative hepatectomy than those with MASLD or HBV alone.

Coexisting steatotic liver disease is not associated with long-term liver-related events in patients with chronic hepatitis B

Steatotic liver disease (SLD) is an emerging liver disease, whereas chronic viral hepatitis is the renowned cause of chronic liver disease leading to cirrhosis and hepatocellular carcinoma (HCC). The impact of coexisting SLD in chronic hepatitis B (CHB) on liver-related events (LREs) in the long term is still debated. This study aims to compare all-cause mortality and LRE between CHB patients with and without SLD. This retrospective study included CHB patients who underwent transient elastography between 2014 and 2021 at a tertiary-care hospital. Exclusion criteria were those without controlled attenuated parameter (CAP) results, interquartile range/median of liver stiffness measurement (LSM) > 30%, follow-up time < 6 months, and without hepatitis B virus DNA data during follow-up. SLD was defined as CAP ≥ 248 dB/m, significant liver fibrosis (SF) as LSM ≥ 7 kPa, and cirrhosis as LSM ≥11 kPa or imaging evidence. LRE was defined as the development of HCC and/or cirrhosis complications. Among 532 patients (median follow-up 4.3 years), SLD was present in 161 (30.2%) patients, SF was found in 186 (34.5%) patients, and 104 (19.6%) patients had cirrhosis at baseline. SF was insignificantly more common in SLD patients (40.1% vs 32.4%, P = 0.068). Long-term outcomes showed SF, not SLD, was independently associated with higher LRE development with an adjusted HR of 13.85 (95% confidence interval [CI]: 3.06-62.76, P < 0.001), while the adjusted HR of SLD was 0.49 (95% CI: 0.16-1.53, P = 0.22). In conclusion, SLD commonly coexists with CHB patients. CHB patients with SLD were more likely to have SF at baseline, albeit not significantly. Long-term HCC and cirrhosis complications development are associated with SF but not SLD status.

Impact of hepatic steatosis on the efficacy of antiviral treatment for chronic hepatitis B and the establishment of predictive model: a cohort study

AIM

Metabolic dysfunction-associated steatotic disease (MASLD) and chronic hepatitis B (CHB) are prevalent liver disorders. Ongoing discussions investigate the impact of MASLD on the therapeutic outcomes of CHB.

METHODS

A cohort of 320 CHB patients on antiviral therapy (including NAs and PEG IFNα) were included and categorized into CHB + MASLD (n = 125) and CHB group (n = 195). The treatment response rates, Kaplan-Meier survival analysis, and Cox regression were assessed between the two groups to investigate the impact of MASLD on antiviral responses in patients with CHB.

RESULTS

At weeks 24 and 48, the CHB + MASLD group displayed a higher HBsAg response rate than the CHB group (24 weeks: 11.5% vs. 3.8%, p = 0.026; 48 weeks: 24.4% vs. 8.4%, p = 0.001). The pgRNA response was also higher in the CHB + MASLD group at both time points (24 weeks: 30.9% vs. 19.7%, p = 0.163; 48 weeks: 48.8% vs. 28.3%, p = 0.049). Kaplan-Meier survival analysis revealed a shorter median time to HBsAg response at 48 weeks for the CHB + MASLD group (HR = 3.251, 40 weeks vs. 42.5 weeks, p = 0.002). This is particularly evident among individuals who are negative for HBeAg (48w: 24.2% vs 12.2%, p = 0.005). KM survival analysis demonstrated that the CHB + MASLD group was more likely to achieve HBsAg response (HR = 2.428, p = 0.039).COX regression analysis identified age (HR = 0.948, p = 0.005), antiviral regimen (NAs + PEG IFNα: HR = 5.33, p < 0.001; PEG IFNα: HR = 1.099, p = 0.93), baseline HBsAg level (HR = 0.648, p = 0.009), and MASLD presence (HR = 3.321, p = 0.002) as independent predictors for HBsAg response. Time-ROC analysis showed that these factors effectively predicted HBsAg decline (24 weeks: AUC = 0.902; 48 weeks: AUC = 0.890). The model demonstrated strong discriminative power, calibration, and clinical relevance.

CONCLUSION

In CHB patients without significant liver fibrosis who receive antiviral therapy, concurrent MASLD enhances HBsAg response, particularly in HBeAg-negative patients. Factors like younger age, NAs with PEG IFNα therapy, lower initial HBsAg levels, and MASLD presence predict treatment success. Further investigations are required to elucidate the impact of diverse metabolic disorders on the advancement of liver fibrosis.

TRIAL REGISTRATION

Registry and the registration No. Of the study/trial: ChiCTR23000 74064(2023-07-28).

Update on the treatment navigation for functional cure of chronic hepatitis B: Expert consensus 2.0

As new evidence emerges, treatment strategies toward the functional cure of chronic hepatitis B are evolving. In 2019, a panel of national hepatologists published a Consensus Statement on the functional cure of chronic hepatitis B. Currently, an international group of hepatologists has been assembled to evaluate research since the publication of the original consensus, and to collaboratively develop the updated statements. The 2.0 Consensus was aimed to update the original consensus with the latest available studies, and provide a comprehensive overview of the current relevant scientific literatures regarding functional cure of hepatitis B, with a particular focus on issues that are not yet fully clarified. These cover the definition of functional cure of hepatitis B, its mechanisms and barriers, the effective strategies and treatment roadmap to achieve this endpoint, in particular new surrogate biomarkers used to measure efficacy or to predict response, and the appropriate approach to pursuing a functional cure in special populations, the development of emerging antivirals and immunomodulators with potential for curing hepatitis B. The statements are primarily intended to offer international guidance for clinicians in their practice to enhance the functional cure rate of chronic hepatitis B.

Pre-Existing and New-Onset Metabolic Dysfunctions Increase Cirrhosis and Its Complication Risks in Chronic Hepatitis B

INTRODUCTION

The prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD) is increasing among the chronic hepatitis B (CHB) population. This study aimed to explore the impact of metabolic dysfunction (MD) on cirrhosis and cirrhotic complication risks in CHB.

METHODS

Patients with CHB were consecutively recruited between 2006 and 2021. The presence of MD was based on the 5 cardiometabolic criteria specified in the MASLD definition. Patients were categorized into MD/non-MD groups based on these criteria.

RESULTS

Eleven thousand five hundred two treatment-naive noncirrhotic patients with CHB were included with a median follow-up of 5.3 years. Patients in the MD group (n = 7,314) were older and had lower hepatitis B virus DNA levels than non-MD patients (n = 4,188). After adjustment for clinical and viral factors, MD patients had significantly higher risks of cirrhosis (adjusted hazard ratio [aHR]: 1.82, 95% confidence interval [CI]: 1.40-2.37, P < 0.001) and cirrhotic complications (aHR: 1.30 per MD, 95% CI: 1.03-1.63, P = 0.025) in a dose-dependent manner. Furthermore, new-onset diabetes mellitus during the follow-up aggravated the risk of cirrhotic complications (aHR: 2.87, 95% CI: 1.34-6.11, P = 0.006). Hepatic steatosis was associated with lower risks of cirrhosis (aHR: 0.57 within 5 years, 95% CI: 0.44-0.74, P < 0.001) and cirrhotic complications (aHR: 0.45, 95% CI 0.23-0.88, P = 0.020). Among individuals with hepatic steatosis, patients with MASLD exhibited a higher cirrhosis risk than non-MD patients.

DISCUSSION

Concurrent and new-onset MDs increase the risks of cirrhosis and cirrhotic complications in patients with CHB, independent of hepatic steatosis. Proactively investigating metabolic comorbidities in CHB is critical to stratify the risk of liver disease progression.

Mechanisms of hepatocellular carcinoma and cirrhosis development in concurrent steatotic liver disease and chronic hepatitis B

Chronic hepatitis B (CHB) poses a major global public health challenge and is a leading cause of cirrhosis and liver cancer. Hepatic steatosis is common in individuals with CHB compared to the non-CHB population and is particularly prevalent in hepatitis B virus (HBV)-endemic regions, affecting about one-third of CHB patients. The interaction between hepatic steatosis and CHB-related disease progression is complex and still under debate. Evidence demonstrates that co-existing steatosis may worsen liver fibrosis while paradoxically increasing the likelihood of achieving better HBV control. In particular, despite the association of steatotic liver disease (SLD) with lower HBV viral loads and higher rates of HBsAg seroclearance, the coexistence of CHB and SLD can potentially accelerate liver disease progression. Factors such as fat deposition, lipotoxicity, oxidative stress, and chronic inflammation in SLD may foster a pro-fibrotic and pro-carcinogenic environment, accelerating the disease progression. Additionally, loss of global DNA methylation, changes in the immune microenvironment, and genetic susceptibility further contribute to the development of CHB-related cirrhosis and hepatocellular carcinoma (HCC). This review examines the mechanisms driving liver disease progression and the heightened risk of cirrhosis and HCC in patients with concurrent CHB and steatotic liver disease, underscoring the importance of prioritizing antiviral therapy for CHB in addition to addressing SLD.

Hepatitis B virus infection and metabolic dysfunction associated steatotic liver disease: Rising pandemic with complex interaction

Due to sedentary lifestyle and rising prevalence of obesity, patients with general population and those who are infected with chronic hepatitis B are found to have metabolic dysfunction associated steatotic liver disease (MASLD). Both chronic hepatitis B virus (HBV) infection and MASLD can damage hepatocytes in their own way, but concomitant HBV-MASLD has its own clinical implications. Cherry on top is the presence of diabetes mellitus, hypertension or obesity which added more chances of unfavorable outcomes in these patients. In this article, we comment on the article by Wang et al published in the recent issue. This article provides a comprehensive overview of the complex interaction between HBV-MASLD, HBV alone and MASLD alone patients. We discuss key findings from recent studies, including the promising outcomes observed in patients with concurrent HBV and MASLD, warrants further research. The insights presented here offer renewed understanding of this complex interaction.

Outcomes of radiofrequency ablation for hepatocellular carcinoma with concurrent steatotic liver disease

BACKGROUND

Steatotic liver disease (SLD) is an emerging liver disease that has been associated with an increased risk for hepatocellular carcinoma (HCC). The impact of concurrent SLD on the prognosis of HCC remains unknown. This study investigates how concurrent SLD affects the outcomes of patients with HCC undergoing curative radiofrequency ablation (RFA) therapy.

METHODS

A retrospective analysis of patients with early-stage HCC receiving curative RFA at a tertiary medical center was conducted. Laboratory data and HCC characteristics were recorded and analyzed by a Cox proportional hazards regression model to predict recurrence and all-cause mortality after RFA.

RESULTS

A total of 598 patients with HCC were included between 2005 and 2015, with 139 and 459 classified in SLD and non-SLD groups, respectively. The SLD group exhibited a significantly better liver reserve and a lower cumulative incidence of HCC recurrence and liver-related and all-cause mortality after a median follow-up of 51 months. After adjusting for metabolic dysfunction, liver reserve, and HCC characteristics, the presence of SLD reduced all-cause mortality (adjusted hazard ratio [aHR], 0.67; 95% confidence interval [CI], 0.45-0.996; p = .048), which was supported by inverse probability weighting analysis (aHR, 0.65; 95% CI, 0.42-1.00; p = .049). Poor liver functional reserve (high albumin-bilirubin grades) increased all-cause mortality dose dependently. Barcelona Clinic Liver Cancer staging and a higher Fibrosis-4 index were predictors for HCC recurrence, whereas SLD was not.

CONCLUSIONS

Among patients with HCC undergoing curative RFA, those with concurrent SLD had a lower risk of all-cause mortality compared to those with poor liver functional reserve.

PLAIN LANGUAGE SUMMARY

The present research demonstrated that patients with both liver cancer and steatotic liver disease who received curative radiofrequency ablation for liver cancer survived longer compared to those without steatotic liver disease. Maintaining good liver function is an important prognostic factor for survival.

Achieving chronic hepatitis B functional cure: Factors and potential mechanisms

Chronic hepatitis B (CHB) is a significant global health issue affecting approximately 254 million individuals worldwide. Achieving the loss of hepatitis B surface antigen (HBsAg), either with or without seroconversion to hepatitis B surface antibody (HBsAb), is regarded as a functional cure and the optimal goal for addressing CHB, and can be achieved through various approaches, including induction with nucleos(t)ide analogues (NAs), induction with pegylated interferon alpha (PegIFNα), and spontaneous clearance of HBsAg. Spontaneous clearance of HBsAg is rare, while NAs can directly inhibit HBV DNA, they are unable to act on covalently closed circular DNA (cccDNA), hence inhibiting HBsAg production or clearing HBsAg is extremely challenging. On the other hand, functional cure based on PegIFNα shows good long-term durability, but over 10 % of patients still experience relapse, mostly within 48 weeks after functional cure. Factors related to CHB functional cure with antiviral therapy are complex, including host factors, viral factors, environmental factors, etc. The integration of HBV DNA into liver cells, persistence of HBV cccDNA, insufficient B cell responses and compromised T cell function pose significant barriers to HBV clearance. Therefore, this study systematically reviewed the relevant factors and potential mechanisms influencing functional cure CHB, which can provide a basis for personalized treatment, help predict treatment outcomes and assess prognosis, and provide theoretical support for the advancement of novel treatment strategies and medications.

All-cause and cause-specific mortality in patients with chronic hepatitis B and concurrent steatotic liver disease

BACKGROUND & AIMS

Steatotic liver disease (SLD) is prevalent among patients with chronic hepatitis B (CHB). However, the effects of metabolic dysfunction-associated SLD (MASLD) on the long-term survival of such patients remain unknown. Accordingly, this study investigated the mortality risks in patients with CHB and concurrent SLD.

METHODS

Consecutive patients with CHB and concurrent SLD were retrospectively recruited at National Taiwan University Hospital. MASLD was defined by the presence of cardiometabolic risk factors. The cumulative incidences of all-cause and cause-specific mortality were compared.

RESULTS

A total of 8,718 patients with CHB and concurrent SLD were included from 2006 to 2021. At baseline, the MASLD group (n = 6,562) was older and had a lower proportion of HBeAg positivity and lower HBV DNA levels compared with the non-MASLD group (n = 2,156). After a median follow-up period of 9.1 years, the MASLD group exhibited a higher risk of all-cause mortality compared with the non-MASLD group (adjusted hazard ratio 1.79, 95% CI 1.24-2.58, p = 0.002). Furthermore, cumulative cardiometabolic risk factors dose-dependently elevated the risks of all-cause, liver-related, and cardiovascular mortality (all p <0.05). During the follow-up period, new-onset diabetes mellitus, hypertension, and significant weight gain further increased the risks of all-cause and liver-related mortality (all p <0.05). However, patients with SLD had a lower mortality risk than those without SLD after propensity score matching (hazard ratio 0.62, 95% CI 0.53-0.74, p <0.001).

CONCLUSIONS

Among patients with CHB and SLD, metabolic burden dose-dependently increases all-cause, liver-related, and cardiovascular mortality risks. Patients with SLD have a lower mortality risk than those without SLD. Identifying these metabolic dysfunctions is crucial for stratifying the level of risk in daily care.

IMPACT AND IMPLICATIONS

Concurrent steatotic liver disease (SLD) is prevalent among patients with chronic hepatitis B (CHB); however, the effects of the associated cardiometabolic risk factors on all-cause and cause-specific mortality remain unknown. This study demonstrated that cumulative metabolic burden dose-dependently increased the risks of all-cause, liver-related, and cardiovascular mortality in patients with CHB and SLD. Moreover, new-onset diabetes mellitus, hypertension, and weight gain during the follow-up period further exacerbated these risks. However, patients with SLD had a lower risk of mortality than those without SLD. Thus, routine screening and monitoring of metabolic dysfunctions constitute a key element of daily care for patients with CHB.

Effect of dyslipidemia on HBsAg clearance in nucleos(t)ide analogues-experienced chronic hepatitis B patients treated with peginterferon alfa

BACKGROUND

While previous reports have shown that hepatitis B virus (HBV) infection affects lipid metabolism and vice versa, the impact of dyslipidemia on the functional cure of HBV infection following peginterferon alfa (PegIFNα) therapy remains unknown. Hence, this study aimed to investigate the effect of dyslipidemia on hepatitis B surface antigen (HBsAg) clearance and develop a nomogram model for predicting patients for whom PegIFNα therapy is indicated.

METHODS

A total of 160 nucleos(t)ide analogues (NAs)- experienced chronic hepatitis B (CHB) patients treated with PegIFNα (180 µg/week) were enrolled in this study. The relationship between serum lipid and HBsAg clearance was analysed. Univariate and multivariate COX analyses were used to construct and plot the nomogram model. The area under the receiver operating characteristic curve (AUC) and calibration curve were used to evaluate the discrimination and calibration of the model, respectively.

RESULTS

After 48 weeks of PegIFNα therapy, a total of 33 patients in the cohort achieved HBsAg clearance. Univariate and multivariate COX analyses indicated that dyslipidemia was significantly associated with HBsAg clearance and was an independent predictor of HBsAg clearance (HR = 0.243, P = 0.001). Kaplan-Meier survival analyses show that cumulative HBsAg clearance was significantly higher in the normolipidemic group than in the dyslipidemia group (log-rank test, P = 0.007). During the treatment, triglyceride showed an increasing trend, while the levels of total cholesterol, high-density lipoprotein, low-density lipoprotein, apolipoprotein A1 and apolipoprotein B decreased. Dyslipidemia and other indicators independently associated with HBsAg clearance were used to construct the nomogram model. The AUC of the model at 36-week and 48-week were 0.879 and 0.856, and the model demonstrated good discrimination and calibration.

CONCLUSION

Dyslipidemia can affect the antiviral efficacy of PegIFNα in NAs-experienced CHB patients. Our findings suggest that the nomogram model constructed using serum lipid has good predictive power and may help physicians to identify the superior patients for PegIFNα therapy.

Impact of concurrent MASLD on early-stage HCC following curative resection in chronic hepatitis B

In 2023, a new nomenclature, metabolic dysfunction-associated steatotic liver disease (MASLD), replaced the term non-alcoholic fatty liver disease (NAFLD). With the global rise in MASLD prevalence, concurrent MASLD and chronic hepatitis B (CHB)-related hepatocellular carcinoma (HCC) are becoming increasingly common. This study aimed to evaluate the clinical impact of concurrent MASLD on long-term survival outcomes in patients with CHB-related early-stage HCC following curative resection. This retrospective study included patients diagnosed with CHB-related early-stage HCC who underwent curative hepatectomy between January 2010 and December 2019. We examined the association between histologically confirmed MASLD and clinical outcomes, with overall survival (OS) and recurrence-free survival (RFS) calculated using the Kaplan-Meier method and compared using the log-rank test. Of 587 eligible patients, 275 (46.8%) were diagnosed with concurrent MASLD. Patients with concurrent MASLD had a higher prevalence of diabetes, hypertension, body mass index (BMI) > 23 kg/m2, a lower proportion of AFP > 200 ng/ml, and microvascular invasion compared to those without MASLD. After a median follow-up of 66 months, patients with concurrent MASLD exhibited a lower risk of death (HR: 0.57, 95% CI: 0.34-0.95, P = 0.030) but no significant difference in HCC recurrence rates. Subgroup analysis revealed significantly higher OS in females, individuals with BMI ≥ 23 kg/m2, and non-cirrhotic patients (all P < 0.05). In conclusion, concurrent MASLD is associated with improved survival in patients with CHB-related HCC following curative resection, particularly in females, those with BMI ≥ 23 kg/m2, and non-cirrhotic patients.

Factors Positively Correlated with Hepatitis B Surface Antigen Seroconversion in Chronic Hepatitis B

BACKGROUND AND AIMS

Chronic hepatitis B virus (HBV) infection is a global public health challenge since more than 250 million individuals are affected worldwide. Since different treatment modalities are available and not all patients are candidates for antiviral treatment, biomarkers that potentially predict the possibility of HBsAg clearance and seroconversion may be useful in clinical practice.

PATIENTS AND METHODS

In this retrospective study, we aimed to identify factors positively correlated with HBsAg seroconversion in a large cohort of 371 chronic hepatitis B patients treated at a German tertial center between 2005 and 2020.

RESULTS

Seroconversion occurred in 25/371 (6.7%) and HBsAg loss in 29/371 patients (7.8%) with chronic HBV infection. Antiviral therapy was associated with a lower chance of seroconversion (seroconversion antiviral therapy 14/260 (5.4%) vs. therapy-naïve patients 11/111 (9.9%), p = 0.027). Seroconversion rates were higher in patients with (very) low titers of HBV DNA (best cut-off value 357 IU/mL) and quantitative HBsAg. The best cut-off value with regard to seroconversion was 357 IU/mL for HBV DNA (AUC 0.693 (95%-CI 0.063-0.422), sensitivity 0.714, specificity 0.729; p < 0.0005) and 33,55 IU/mL for HBsAg (AUC 0.794 (95%-CI 0.651-0.937), sensitivity 0.714, specificity 0.949; p < 0.0005). However, male gender was positively associated with seroconversion (seroconversion: males 7.6% vs. females 2.7%, p = 0.036).

CONCLUSIONS

Treatment-naïve male chronic HBV patients with low viral load and inflammatory activity have the best chance to achieve seroconversion. In the absence of cirrhosis, antiviral therapy should therefore not be performed in this patient collective.