Metabolic syndrome increases cardiovascular events but not hepatic events and death in patients with chronic hepatitis B

Enhanced Predictive Value of Lipid Accumulation Product for Identifying Metabolic Syndrome in the General Population of China

The purpose of this research was to evaluate the lipid accumulation product (LAP)'s accuracy and predictive value for identifying metabolic syndrome (MS) in the general Chinese population compared with other obesity indicators. Baseline survey information from a population-based cohort study carried out in Shanghai's Songjiang District was used in this research. Odds ratios (OR) and a 95% confidence interval (CI) were obtained by logistic regression. The ability of each variable to detect MS was assessed using the receiver operating characteristic curve (ROC). The optimum cut-off point for each indicator was selected using Youden's index. The survey involved 35,446 participants in total. In both genders, the prevalence of MS rose as the LAP increased (p < 0.001). The LAP's AUC was 0.901 (95%CI: 0.895-0.906) in males and 0.898 (95%CI: 0.893-0.902) in females, making it substantially more predictive of MS than other variables (BMI, WC, WHR, WHtR). The optimal cutoff point of the LAP for men and women was 36.04 (Se: 81.91%, Sp: 81.06%) and 34.95 (Se: 80.93%, Sp: 83.04%). The Youden index of the LAP was 0.64 for both sexes. Our findings imply that the LAP, compared to other obesity markers in China, is a more accurate predictor of MS.

Hepatic steatosis and metabolic risk factors among patients with chronic hepatitis B: The multicentre, prospective CAP-Asia study

We aimed to compare the severity of liver disease, metabolic profile and cardiovascular disease (CVD) risk of chronic hepatitis B (CHB) patients with and without hepatic steatosis and patients with non-alcoholic fatty liver disease (NAFLD). Patients with NAFLD and CHB were prospectively enrolled from 10 Asian centres. Fibroscan was performed for all patients and hepatic steatosis was defined based on controlled attenuation parameter >248 dB/m. CVD risk was assessed using the Framingham risk score. The data for 1080 patients were analysed (67% NAFLD, 33% CHB). A high proportion (59%) of CHB patients had hepatic steatosis. There was a significant stepwise increase in alanine aminotransferase, aspartate aminotransferase, gamma-glutamyl transpeptidase, controlled attenuation parameter and liver stiffness measurement, from CHB patients without hepatic steatosis to CHB patients with hepatic steatosis to NAFLD patients (p < 0.001 for all comparisons). There was a significant stepwise increase in the proportion of patients with metabolic syndrome and in CVD risk, with very high or extreme CVD risk seen in 20%, 48% and 61%, across the groups (p < 0.001 between CHB patients with and without hepatic steatosis and p < 0.05 between CHB patients with hepatic steatosis and NAFLD patients). In conclusion, there was a high proportion of CHB patients with hepatic steatosis, which should be diagnosed, as they may have more severe liver disease, so that this and their metabolic risk factors can be assessed and managed accordingly for a better long-term outcome.

Clinical impact and mechanisms of hepatitis B virus infection concurrent with non-alcoholic fatty liver disease

ABSTRACT

Chronic hepatitis B (CHB) virus infection is an important threat to global health despite the administration of vaccines and the use of antiviral treatments. In recent years, as the prevalence of obesity and metabolic syndrome has increased, non-alcoholic fatty liver disease (NAFLD) in patients with CHB has become more common. Both diseases can lead to liver fibrosis and even hepatocellular carcinoma, but the risk of dual etiology, outcome, and CHB combined with NAFLD is not fully elucidated. In this review, we assess the overlapping prevalence of NAFLD and CHB, summarize recent studies of clinical and basic research related to potential interactions, and evaluate the progressive changes of treatments for CHB patients with NAFLD. This review increases the understanding of the relationship and mechanisms of interaction between steatosis and hepatitis B virus infection, and it provides new strategies for the future clinical management and treatment of CHB combined with NAFLD.

Application of Fatty Liver Inhibition of Progression Algorithm and Steatosis, Activity, and Fibrosis Score to Assess the Impact of Non-Alcoholic Fatty Liver on Untreated Chronic Hepatitis B Patients

Backgrounds and Purpose

Concurrent non-alcoholic fatty liver disease (NAFLD) in chronic hepatitis B (CHB) patients is a frequent and increasingly concerning problem because of the NAFLD pandemic. Admittedly, NAFLD can progress to non-alcoholic steatohepatitis (NASH) and severe fibrosis. Direct evidence of the fibrotic effect of NAFLD or NASH in chronic hepatitis B virus (HBV) infection remains lacking. We aimed to reveal the influence of concurrent histologically proven fatty liver diseases in fibrogenesis with chronic HBV infection.

Methods

We performed a retrospective cross-sectional study on a liver biopsy population of CHB patients without excessive alcohol intake to evaluate the prevalence of concurrent histologically proven NAFLD or NASH according to the fatty liver inhibition of progression (FLIP) algorithm and its association with the liver fibrosis stage.

Results

Among 1,081 CHB patients, concurrent NAFLD was found in 404 patients (37.4%), among whom 24.0% (97/404) have NASH. The presence of NASH was an independent predictor of significant fibrosis (odds ratio (OR), 2.53; 95% CI, 1.52–4.21; p < 0.001) and severe fibrosis (OR, 1.83; 95% CI, 1.09–3.09; p = 0.023) in all patients, as well as in patients with normal alanine aminotransferase (ALT) (predicting significant fibrosis, OR, 2.86, 95% CI, 1.34–6.10; p = 0.007). The presence of lobular inflammation (p < 0.001) or presence of cytological ballooning (p < 0.001), rather than presence of steatosis (p = 0.419), was related with severity of fibrosis in Spearman’s correlation analysis.

Conclusions

Concurrent NAFLD is common in CHB patients, and NASH is an independent risk factor potentiating significant fibrosis by 2.53-fold and severe fibrosis by 1.83-fold. While coping with chronic HBV infection, routine assessment of co-existing NAFLD or NASH is also important.

Modeling of diagnosis for metabolic syndrome by integrating symptoms into physiochemical indexes

BACKGROUND

Metabolic syndrome (MS) is a major global health concern comprising a cluster of co-occurring conditions that increase the risk of heart disease, stroke and type 2 diabetes. MS is usually diagnosed using a combination of physiochemical indexes (such as BMI, abdominal circumference and blood pressure) but largely ignores clinical symptoms when investigating prevention and treatment of the disease. Exploring predictors of MS using multiple diagnostic indicators may improve early diagnosis and treatment of MS. Traditional Chinese medicine (TCM) attaches importance to the etiology of disease symptoms and indications using four diagnostic methods, which have long been used to treat metabolic disease. Therefore, in this study, we aimed to develop predictive indicators for MS using both physiochemical indexes and TCM methods.

METHODS

Clinical information (including both physiochemical and TCM indexes) was obtained from a cohort of 586 individuals across 4 hospitals in China, comprising 136 healthy controls and 450 MS cases. Using this cohort, we compared three classic machine learning methods: decision tree (DT), support vector machine (SVM) and random forest (RF) towards MS diagnosis using physiochemical and TCM indexes, with the best model selected by comparing the accuracy, specificity and sensitivity of the three models. In parallel, the best proportional partition of the training data to the test data was confirmed by observing the changes in evaluation indexes using each model. Next, three subsets containing different categories of variables (including both TCM and physicochemical indexes combined - termed the "fused indexes", only physicochemical indexes, and TCM indexes only) were compared and analyzed using the best performing model and optimum training to test data proportion. Next, the best subset was selected through comprehensive comparative analysis, and then the important prediction variables were selected according to their weight.

RESULTS

When comparing the three models, we found that the RF model had the highest average accuracy (average 0.942, 95%CI [0.925, 0.958]) and sensitivity (average 0.993, 95%CI [0.990, 0.996]). Besides, when the training set accounted for 80% of the cohort data, the specificity got the best value and the accuracy and sensitivity were also very high in RF model. In view of the performance of the three different subsets, the prediction accuracy and sensitivity of models analyzing the fused indexes and only physicochemical indexes remained at a high level. Further, the mean value of specificity of the model using fused indexes was 0.916, which was significantly higher than the model with only physicochemical indexes (average 0.822) and the model with only TCM indexes (average 0.403). Based on the RF model and data allocation ratio (8:2), we further extracted the top 20 most significant variables from the fused indexes, which included 14 physicochemical indexes and 6 TCM indexes including wiry pulse, chest tightness, spontaneous perspiration, greasy tongue coating etc. CONCLUSION: Compared with SVM and DT models, the RF model showed the best performance, especially when the ratio of the training set to test set is 8:2. Compared with single predictive indexes, the model constructed by combining physiochemical indexes with TCM indexes (i.e. the fused indexes) exhibited better predictive ability. In addition to common physicochemical indexes, some TCM indexes, such as wiry pulse, chest tightness, spontaneous perspiration, greasy tongue coating, can also improve diagnosis of MS.

Controlled attenuation parameter value-based diagnostic algorithm improves the accuracy of liver stiffness measurement in chronic hepatitis B patients

Liver stiffness measurement (LSM) frequently overestimates the severity of liver fibrosis because of steatosis. However, the impact of the controlled attenuation parameter (CAP) on liver stiffness cutoff values remains unknown; CAP was used to quantify and diagnose the severity of hepatic steatosis. The study was conducted to determine the effect of CAP on liver stiffness cutoff values in chronic hepatitis B (CHB) patients. A retrospective cross-sectional study was performed in liver biopsy-proven CHB patients. The median LSM (kPa) in the elevated CAP group was higher than that in the normal CAP group at the same fibrosis stage. For S2-4, the area under the receiver operating characteristic (AUROC) curve of LSM was 0.78 and 0.72 in the normal and elevated CAP groups, respectively. When a cutoff value of 8.9 kPa was used, the diagnostic accuracy was 77.82% and 63.41% in the normal and elevated CAP groups, respectively. Compared with the alanine transaminase (ALT)-based LSM algorithm, the CAP-based LSM algorithm had a similar correct diagnosis rate (33.64% vs. 33.94%, respectively) but a lower misdiagnosis rate (16.97% vs. 20.30%, respectively). The new CAP-based LSM diagnostic algorithm will improve the diagnostic accuracy of liver fibrosis in CHB patients.

Influence of Besifovir Dipivoxil Maleate Combined with L-Carnitine on Hepatic Steatosis in Patients with Chronic Hepatitis B

BACKGROUND

Besifovir dipivoxil maleate (BSV) with L-carnitine is the first-line antiviral agent for chronic hepatitis B (CHB) infection. We investigated whether BSV combined with L-carnitine improves hepatic steatosis (HS).

METHODS

Treatment-naïve patients with CHB who were initiated on antiviral therapy (AVT) were enrolled. The magnitude of HS was assessed using hepatic steatosis index (HSI), and HS improvement was defined as a ≥ 10% reduction in the HSI score from the baseline.

RESULTS

The mean age of the study patients was 56 years with a male predominance (n = 178, 64.7%). The mean body mass index (BMI), aspartate aminotransferase (AST), alanine aminotransferase (ALT), and platelet count were 23.5 kg/m², 49.6 IU/L, 49.0 IU/L, and 191.3 × 10⁹/L, respectively. The mean HSI and fibrosis (FIB)-4 index were 32.6 and 0.5, respectively. After 6 months of AVT, platelet count (mean, 191.3→167.0 × 10⁹/L), fasting glucose (mean, 113.1→105.9 mg/dL), AST (mean, 49.6→28.0 IU/L), ALT (mean, 49.0→33.9 IU/L), and total cholesterol (mean, 170.0→162.1 mg/dL) levels significantly decreased (all P < 0.05). In the BSV group, AST (mean, 95.2→30.2 IU/L) and ALT (mean, 81.1→31.1 IU/L) levels significantly reduced (all P < 0.05), whereas HSI and FIB-4 index were maintained (all P > 0.05). In the univariate analysis, age, BMI, diabetes, cirrhosis, fasting glucose level, and ALT were significantly associated with HS improvement (all P < 0.05).

CONCLUSION

BSV with L-carnitine did not show any improvement of HS in patients with CHB. Further prospective randomized controlled studies are needed to validate the potential beneficial effects of BSV with L-carnitine in CHB infection.

An Aging Population of Chronic Hepatitis B With Increasing Comorbidities: A Territory-Wide Study From 2000 to 2017

Patients with chronic hepatitis B (CHB) are aging because of improved survival under better health care. This has an important implication on the choice of antiviral treatment (AVT), given that long-term safety would be a concern in the presence of multiple comorbidities. We aimed to determine the prevalence of key comorbidities and concomitant medications in a territory-wide CHB cohort in Hong Kong in 2000-2017. CHB patients who have been under the care at primary, secondary, and tertiary medical centers in the public sector were identified through the Clinical Data Analysis and Reporting System of the Hospital Authority, Hong Kong. The demographics and prevalence of key comorbidities, including diabetes mellitus, hypertension, chronic kidney disease, osteopenia/osteoporosis based on diagnosis codes, relevant medications, and/or laboratory parameters, were determined according to CHB patients' first appearance in four time periods: 2000-2004, 2005-2009, 2010-2013, and 2014-2017. In the final analysis, 135,395 CHB patients were included; the mean age increased with time: 41 ± 15 years in 2000-2004; 46 ± 17 years in 2005-2009; 51 ± 16 years in 2010-2013; and 55 ± 15 years in 2014-2017. There was a trend of increasing prevalence of several common comorbidities over the four periods: hypertension 25.5%, 23.8%, 27.2%, and 28.6%; diabetes mellitus 10.6%, 12.5%, 16.1%, and 20.1%; cardiovascular disease 12.5%, 16.9%, 20.9%, and 22.2%; and malignancy 7.0%, 13.2%, 17.3%, and 23.6%, respectively (all P < 0.001). Conclusion: CHB patients are getting older with increasing prevalence of common comorbidities. These comorbidities should be taken into account when choosing AVT.

Protective Effect of Hepatitis B Against Metabolic Syndrome in Patients with Nonalcoholic Fatty Liver Disease But Not in Normal Individuals

Background: Both hepatitis B (HB) and nonalcoholic fatty liver disease (NAFLD) are related to metabolic syndrome (MetS); however, this relationship remains controversial. In this study, we determined the effects of NAFLD and HB infection on the risk of MetS among elderly individuals. Methods: In total, 24,500 individuals aged >65 years were enrolled; they were classified into four groups: normal individuals (N), patients with only HB infection without abnormal echogenicity (HB-alone), patients with only abnormal echogenicity or fatty liver alone (FL-alone), and patients with both HB infection and abnormal echogenicity (HB-FL). Results: After adjustment for age, compared with group N, men and women with NAFLD (FL-alone and HB-FL) had a significantly higher risk of MetS, whereas no significant difference was observed in the incidence of MetS between groups HB-alone and N. However, group HB-FL had a lower risk of MetS than did group FL-alone. HB infection (HB-alone and HB-FL) was associated with a lower risk of high triglycerides (TGs) and fasting plasma glucose (FPG) than HB infection absence (groups N and FL-alone) in men and women. Lower risk of TG derangement was observed in group HB-alone than in group N. In addition, both men and women in group HB-FL had a lower risk of TG and FPG abnormalities than in group FL-alone, whereas a decrease in incidence of high waist circumference and blood pressure was observed only in men. Conclusion: HB infection protects against MetS development, only in patients with HB infection and NAFLD, but not in normal individuals. Additional studies are warranted to clarify the pathogenesis.

Metabolic syndrome and liver-related events: a systematic review and meta-analysis

BACKGROUND

Previous studies have suggested that metabolic syndrome (MetS) and its component conditions are linked to the development of many benign or malignant diseases. Some studies have described relationships among metabolic syndrome or diabetes and liver cancer, but not many articles described the relationships between MetS and cirrhosis, acute hepatic failure, end-stage liver disease, and even death. However, liver cancers, cirrhosis, acute hepatic failure, end-stage liver disease, and liver-related mortality-collectively described as liver-related events (LREs)-may have different relationships with MetS. We undertook this meta-analysis to examine the association between MetS and LREs, and to determine whether geographic region or hepatitis B virus (HBV) positivity might influence the association.

METHODS

Relevant studies were identified from PubMed, EMBASE, and the Cochrane database. Two reviewers independently searched records from January 1980 to December 2017. The search terms included 'metabolic syndrome', 'diabetes mellitus', 'insulin resistance syndrome', and 'metabolic abnormalities', combined with 'cirrhosis', 'hepatic fibrosis ', 'hepatocellular carcinoma', 'complication', 'LRE', 'HCC', 'liver-related events', and 'liver cancer'. No language restriction was applied to the search. We chose the studies reporting an association between MetS and LREs. We used Begg's and Egger's tests and visually examined a funnel plot to assess publication bias. All analyses were conducted in Stata 14.0 software.

RESULTS

There were 19 studies (18 cohort and 1 case-control) included in the analysis, with a total of 1,561,457 participants. The subjects' ages ranged from 18 to 84 years. The combined analysis showed an overall 86% increase risk of LREs in cases with MetS (RR: 1.86,95% CI: 1.56-2.23). The funnel plot was asymmetrical, and the Egger's test p values showed a publication bias in this meta analysis. However, through the trim and fill method, we obtained a new RR value for LREs with MetS of 1.49 (95% CI: 1.40-1.58, p = 0.000). There was no obvious difference with the two answers, so we concluded that the results were robust. For hepatitis B positive patients, the RR for MetS and LREs was 2.15 (95% CI:1.02-4.53, p = 0.038), but for the hepatitis B negative patients, the RR was 1.85 (95% CI:1.53-2.24, p = 0.000). And for non-Asians, the RR for MetS and LREs was 2.21 (95% CI: 1.66-2.69, p = 0.000), while for Asians, the RR was 1.73 (95% CI: 1.35-2.22, p = 0.000).

CONCLUSIONS

This meta-analysis showed that MetS is associated with a moderately increased risk of LREs prevalence. Patients with MetS together with hepatitis B are more likely to develop hepatic events. For non-Asians, MetS is more likely to increase the incidence of LREs.

Unmet need in chronic hepatitis B management

Despite all these exciting developments, there remain some unmet needs in the management for patients with chronic hepatitis B (CHB). As majority of CHB patients are going to use oral nucleos(t)ide analogues (NAs) for decades, Safety profile of NAs is of no doubt an important issue. The newest nucleotide analogue tenofovir alafenamide is potent in terms of viral suppression, together with favourable renal and bone safety profile. Biochemical response as reflected by alanine aminotransferase (ALT) normalization is recently found to be prognostically important. Patients who achieved ALT normalization have reduced the risk of hepatic events by 49%. Functional cure as reflected by hepatitis B surface antigen seroclearance not only implies patients may stop NA treatment, it also confers to a reduced risk of hepatocellular carcinoma and other hepatic events. Hence functional cure should be the ultimate treatment goal in CHB patients. Preemptive antiviral treatment may reduce mother-to-child transmission of hepatitis B virus, especially if birth dose of vaccination cannot be given in the first two hours after delivery. Lastly, despite the currently first-line NAs have high-genetic barrier to drug resistance mutations, there are still are many patients who were previously treated with low barrier of resistance including lamivudine, telbivudine or adefovir dipivoxil which could lead to antiviral resistance and affecting the choice of NAs.

Normal on-treatment ALT during antiviral treatment is associated with a lower risk of hepatic events in patients with chronic hepatitis B

BACKGROUND & AIMS

Recent studies reveal that the rate of normal on-treatment alanine aminotransferase (ALT) appears different for different nucleos(t)ide analogues (NAs); yet its clinical significance is unclear. We aimed to evaluate the impact of normal on-treatment ALT during antiviral treatment with entecavir (ETV) or tenofovir disoproxil fumarate (TDF) in patients with chronic hepatitis B (CHB).

METHODS

A territory-wide cohort of patients with CHB who received ETV and/or TDF in 2005-2016 was identified. Serial on-treatment ALT levels were collected and analyzed. Normal on-treatment ALT (ALT-N) was defined as ALT <30 U/L in males and <19 U/L in females. The primary and secondary outcomes were composite hepatic events (including hepatocellular carcinoma) based on diagnostic codes. Patients with hepatic events before or during the first year of antiviral treatment or follow-up <1 year were excluded.

RESULTS

A total of 21,182 patients with CHB (10,437 with and 10,745 without ALT-N at 12 months after antiviral treatment) were identified and followed for 4.0 ± 1.7 years. Patients with and without ALT-N differed in baseline ALT (58 vs. 61 U/L), hepatitis B virus DNA (4.9 vs. 5.1 log10 IU/ml) and cirrhosis status (8.8% vs. 10.5%). A total of 627 (3.0%) patients developed composite hepatic events. Compared to no ALT-N, ALT-N at 3, 6, 9 and 12 months reduced the risk of hepatic events, after adjustment for baseline ALT and other important covariates, with adjusted hazard ratios (95% CI) of 0.61 (0.49-0.77), 0.55 (0.45-0.67), 0.54 (0.44-0.65) and 0.51 (0.42-0.61) respectively (all p <0.001). The cumulative incidence (95% CI) of composite hepatic events at six years was 3.51% (3.06%-4.02%) in ALT-N and 5.70% (5.15%-6.32%) in the no ALT-N group (p <0.001).

CONCLUSIONS

Normal on-treatment ALT is associated with a lower risk of hepatic events in patients with CHB receiving NA treatment, translating into improved clinical outcomes in these patients.

LAY SUMMARY

We investigated 21,182 patients with chronic hepatitis B receiving antiviral treatment. Alanine aminotransferase is a laboratory marker of liver function, with raised levels indicating liver dysfunction and in severe cases hepatitis. Normal on-treatment alanine aminotransferase during the first year of treatment in patients with CHB is associated with a lower risk of hepatic events.

Prognostic Value of Controlled Attenuation Parameter by Transient Elastography

OBJECTIVES

Liver stiffness measurement (LSM) by transient elastography (TE) has been shown to predict outcomes in patients with liver disease. While controlled attenuation parameter (CAP) measurement can accurately quantify hepatic steatosis, its prognostic value is unknown. We aim to determine if CAP is predictive for liver-related events (LRE), non-hepatocellular carcinoma (HCC) cancers, and cardiovascular events (CVE).

METHODS

Consecutive patients with both a reliable LSM and ≥10 successful CAP measurements by TE from August 2012 to March 2016 were included in the analysis. LRE were defined as HCC or hepatic decompensation. CVE were defined as acute coronary syndrome (ACS), cerebrovascular accident (CVA), or coronary intervention (stenting or bypass).

RESULTS

Of the 5,848 patients that were examined, 4,282 (56.7% male, median age 57 years) had adequate follow-up, reliable LSM (median 6.1 kPa), and ≥10 CAP measurements (median 250 dB/m). Indications for TE were: suspected non-alcoholic fatty liver disease (NAFLD) (40.7%), hepatitis B (HBV) (37.0%), hepatitis C (2.9%), and others (19.4%). During 8,540 patient-years of follow-up, there were 45 patients with LRE (34 HCC, 33 decompensations), 73 with newly diagnosed non-HCC cancers, and 65 with CVE (27 ACS, 25 CVA, and 35 coronary interventions). CAP did not predict LRE, non-HCC cancer, or CVE on univariate analysis. On multivariate analysis, LSM, male sex, platelet count, serum albumin, and HBV etiology independently predicted LRE; age was the only independent predictor of non-HCC cancer; while age, fasting blood glucose, total cholesterol, and creatinine predicted for CVE. Subgroup analyses of viral hepatitis and NAFLD patients revealed similar results.

CONCLUSION

Neither the presence nor the severity of hepatic steatosis as measured by CAP predict LRE, cancer, or CVE in the short term.

Sensitivity analysis for mistakenly adjusting for mediators in estimating total effect in observational studies

OBJECTIVES

In observational studies, epidemiologists often attempt to estimate the total effect of an exposure on an outcome of interest. However, when the underlying diagram is unknown and limited knowledge is available, dissecting bias performances is essential to estimating the total effect of an exposure on an outcome when mistakenly adjusting for mediators under logistic regression. Through simulation, we focused on six causal diagrams concerning different roles of mediators. Sensitivity analysis was conducted to assess the bias performances of varying across exposure-mediator effects and mediator-outcome effects when adjusting for the mediator.

SETTING

Based on the causal relationships in the real world, we compared the biases of varying across the effects of exposure-mediator with those of varying across the effects of mediator-outcome when adjusting for the mediator. The magnitude of the bias was defined by the difference between the estimated effect (using logistic regression) and the total effect of the exposure on the outcome.

RESULTS

In four scenarios (a single mediator, two series mediators, two independent parallel mediators or two correlated parallel mediators), the biases of varying across the effects of exposure-mediator were greater than those of varying across the effects of mediator-outcome when adjusting for the mediator. In contrast, in two other scenarios (a single mediator or two independent parallel mediators in the presence of unobserved confounders), the biases of varying across the effects of exposure-mediator were less than those of varying across the effects of mediator-outcome when adjusting for the mediator.

CONCLUSIONS

The biases were more sensitive to the variation of effects of exposure-mediator than the effects of mediator-outcome when adjusting for the mediator in the absence of unobserved confounders, while the biases were more sensitive to the variation of effects of mediator-outcome than those of exposure-mediator in the presence of an unobserved confounder.

Tenofovir disoproxil fumarate significantly decreases serum lipoprotein levels compared with entecavir nucleos(t)ide analogue therapy in chronic hepatitis B carriers

BACKGROUND

Tenofovir disoproxil fumarate (TDF) and entecavir (ETV) are first-line treatments for chronic hepatitis B (CHB). Studies suggest lipid lowering effect of TDF in human immunodeficiency virus positive (HIV+) individuals, but the effect on lipids and cardiovascular disease (CVD) risk in CHB is unknown.

AIM

To compare TDF vs ETV effects on lipid levels in CHB.

METHODS

In this retrospective cohort study, data on serum lipids and CVD risk factors at baseline and ~1 year on TDF or ETV were collected from CHB carriers. We used propensity score matched models to assess the effect on total cholesterol (TC), LDL-C, HDL and triglycerides (TGL).

RESULTS

In 348 patients, median age was 57 (IQR: 47-65 years), 63% were male, 77% were Asian, 19% were cirrhotic, 25% were HBeAg positive at baseline, and 72% received TDF vs 28% ETV. ETV-treated patients were older (median age: 60 vs 55, P<.01), had similar smoking and hypertension rates, but diabetes and dyslipidemia were more prevalent (19% vs 9%, P=.01; 14% vs 6%, P=.05, respectively). In propensity score matched models for age, gender, usage of lipid lowering agents, dyslipidemia and diabetes, TDF-treated patients were more likely to show a 20% decrease in TC (95% CI: 3%-25%), LDL-C (95% CI: 1%-25%) and HDL-C (CI: 10%-30%) levels compared with those on ETV. No change in TGL was observed in either group.

CONCLUSIONS

A greater decline in TC, LDL-C and HDL was observed in CHB carriers receiving TDF compared with ETV. These data may influence anti-viral choice in CHB carriers at risk for CVD.