Need to strictly define hepatitis B virus immunotolerant patients to avoid unnecessary liver biopsy

Histologic changes in immune-tolerant patients with chronic hepatitis B: a systematic review and meta-analysis

The serological diagnostic criteria for the immune-tolerant (IT) phase have not been strictly defined and it is hard to determine an accurate rate for significant histologic changes among IT patients. The aim of this study was to establish a baseline rate of significant histologic changes and to determine the main characteristics of IT patients. We systematically searched PubMed, Embase, and Web of Science. Studies reporting liver biopsy results (inflammation grade or fibrosis stage) for adults with chronic hepatitis B virus (HBV) infection in the IT phase diagnosed by serological criterion were included to pool the rate of significant histologic changes. Studies that enrolled subjects with confirmed chronic HBV infection in the IT phase diagnosed by serological and liver biopsy criteria (dual criteria) were included to pool the mean values of main characteristics among IT patients. Of 319 studies screened, 15 were eventually included in the meta-analysis. The pooled rates of significant liver fibrosis and inflammatory activity for 10 studies were 10% (95% confidence interval [CI] 0.06-0.18) and 16% (95% CI 0.07-0.31), respectively. The pooled mean values of age, alanine aminotransferase level, HBV DNA level, and HBsAg level for another 5 studies with IT patients diagnosed by dual criteria were 30.7 years (95% CI 27.31-34.09), 26.64 IU/mL (95% CI 24.45-28.83), 8.41 log₁₀ cp/mL (95% CI 7.59-9.23), and 4.24 log₁₀ IU/mL (95% CI 3.67-4.82), respectively. Significant histologic changes were not rare events among IT patients. Strictly defined serological diagnostic criteria for the IT phase are warranted.

HBV-carriers: When is monitoring and surveillance sufficient? (point of view)

Medications currently available for the treatment of hepatitis B virus (HBV) infection are highly effective but not curative. The current paradigm is to recognize patients who require long-term treatment (with its inconveniences) among the majority of healthy carriers who do not need treatment. International guidelines have been established to identify patients requiring treatment but differences concerning the cut-off levels for viral load and transaminases, or need for liver biopsy, compromise their interpretation. IMMUNE TOLERANCE PHASE: Patients with strictly defined typical forms (HBeAg-positive, normal transaminases level, very high viral load HBV-DNA more than 2 × 10(6) IU) have very limited liver injury and do not require treatment. Patients with atypical forms (low viral load HBV-DNA less than 2 × 10(6) IU) have a potential risk of more severe histological lesions, but the need for liver biopsy and treatment remains a matter of debate. Immune tolerant patients aged over 40 years should be treated because of the higher risk of hepatocellular carcinoma, even without cirrhosis. ACTIVE PHASE HBEAG-POSITIVE OR NEGATIVE: Typical forms with elevated viral load and transaminases level should be treated. Mild hepatitis with moderately elevated transaminases levels (1-2 times upper limit of normal) can cause variable degrees of liver damage, and liver biopsy is necessary. HBeAg-positive hepatitis with very high transaminases levels have a very high rate of spontaneous HBe seroconversion. Hepatitis with high transaminases levels but low viral (HBV-DNA less than 2000 UI) is possible in HBe-negative patients but unusual in HBe-positive patients. Another cause of liver disease could be involved (hepatitis D, steatosis, alcohol). INACTIVE PHASE: In the typical form, patients have a normal transaminases level and HBV-DNA less than 2000 IU; histological lesions are in general minimal. Treatment is not indicated. Atypical forms with normal transaminases levels but elevated HBV-DNA more than 2000 IU remain problematic. Forms with high-normal transaminases levels have a higher risk of complications. In the event of inactive cirrhosis, treatment is indicated if replication persists, even at a low level.

Endpoints of therapy in chronic hepatitis B

Because clearance of hepatitis B virus (HBV) infection is rarely, if ever, achievable, the goals of therapy necessarily focus on prevention of bad clinical outcomes. Ideally, therapies would be shown to prevent tangible clinical endpoints like development of cirrhosis, end-stage liver disease and hepatocellular carcinoma. However, these endpoints typically take years or decades to occur and are therefore impractical targets for clinical trials which last only 1-2 years. As a result, surrogate biomarkers that are believed to correlate with long-term outcome are used to evaluate therapy. Of the clinical, biochemical, serological, virological, and histological endpoints that have been evaluated, none has been shown to be ideal on its own. Symptoms are uncommon and aminotransferase levels fluctuate spontaneously. Loss of hepatitis B e antigen (HBeAg) has been the traditional therapeutic endpoint; however, the indefinite durability off treatment and the emergence of HBeAg-negative disease have made it inadequate as the sole goal of therapy. Loss of hepatitis B surface antigen is associated with improved clinical outcomes, but it is rarely achieved with current therapies. Suppression of viral replication, as measured by serum HBV DNA levels, has become the major goal of therapy, particularly if maintained off therapy. Although useful, the significance of viral levels depends on the stage of disease, degree of liver damage, and the type of therapy. Finally, liver biopsy, often considered the gold standard, is invasive, prone to sampling error, and may take years to change significantly.At present, there is no ideal biomarker for evaluation of therapies for hepatitis B. Future research should be directed at development and validation of surrogate markers that accurately predict or reflect clinically relevant outcomes of chronic hepatitis B.