Letter: hepatic steatosis and fibrosis in chronic hepatitis B-the chicken-and-egg conundrum. Authors' reply

Metabolic dysfunction-associated fatty liver disease and chronic hepatitis B

Fatty liver disease and chronic hepatitis B (CHB) are the major causes for chronic liver diseases and the associated adverse outcomes. Concurrent hepatic steatosis has been found to inversely correlate with hepatitis B virus (HBV) activity both in vivo and in vitro; however, the subsequent effects on the prognosis, including advanced fibrosis and hepatocellular carcinoma (HCC) development, remain diverse and inconclusive. Although the newly-proposed criteria of metabolic dysfunction-associated fatty liver disease (MAFLD) help raise disease awareness and facilitate timely diagnosis and management, its clinical impact on patients with CHB, especially after taking the metabolic dysfunction into consideration, is largely unknown and warrants comprehensive investigations to improve the management of CHB population. In this review, these relevant issues are summarized and discussed.

Precision medicine in the era of potent antiviral therapy for chronic hepatitis B

With the wide use of potent and safe nucloes(t-)ide analogues (NAs) treatment, patient-centered care is getting important. Intensive care for comorbidity has gain utmost importance in care of aging chronic hepatitis B (CHB) patients with life-long antiviral treatment. Linkage to care of patients with CHB is essential for the goal of hepatitis B virus (HBV) eradication. As long-term suppression of HBV DNA replication does not prevent hepatocellular carcinoma (HCC), prevention of HCC is another challenge for NAs treatment. There is a possibility of hepatocarcinogenesis in the immune-tolerant phase and risk of loss of patients during active monitoring seeking the time point for antiviral treatment initiation. Initiation of NAs treatment from the immune-tolerant phase would improve the linkage to care. However, universal recommendation is premature and evidence for cost-effectiveness needs to be accumulated. Early initiation of NAs in the evidence of significant disease progression, either HBV associated or comorbidity associated, would be a better strategy to reduce the risk of HCC in patients located in the gray zone.