Non-linear association of baseline viral load with on-treatment hepatocellular carcinoma risk in chronic hepatitis B

Viral Load-Based Prediction of Hepatocellular Carcinoma Risk in Noncirrhotic Patients With Chronic Hepatitis B : A Multinational Study for the Development and External Validation of a New Prognostic Model

BACKGROUND

A nonlinear association between serum hepatitis B virus (HBV) DNA levels and hepatocellular carcinoma (HCC) risk has been suggested in patients with chronic hepatitis B (CHB).

OBJECTIVE

To develop and externally validate a prognostic model for HCC risk in noncirrhotic adult patients with CHB and no notable alanine aminotransferase (ALT) elevation.

DESIGN

Multinational cohort study.

SETTING

A community-based cohort in Taiwan (REVEAL-HBV [Risk Evaluation of Viral Load Elevation and Associated Liver Disease/Cancer-Hepatitis B Virus]; REACH-B [Risk Estimation for HCC in CHB] model cohort) and 8 hospital-based cohorts from Korea and Hong Kong (GAG-HCC [Guide with Age, Gender, HBV DNA-HCC] and CU-HCC [Chinese University-HCC] cohorts).

PARTICIPANTS

Model development: 6949 patients with CHB from a Korean hospital-based cohort. External validation: 7429 patients with CHB combined from the Taiwanese cohort and 7 cohorts from Korea and Hong Kong.

MEASUREMENTS

Incidence of HCC.

RESULTS

Over median follow-up periods of 10.0 and 12.2 years, the derivation and validation cohorts identified 435 and 467 incident HCC cases, respectively. Baseline HBV DNA level was one of the strongest predictors of HCC development, demonstrating a nonlinear parabolic association in both cohorts, with moderate viral loads (around 6 log10 IU/mL) showing the highest HCC risk. Additional predictors included in the new model (Revised REACH-B) were age, sex, platelet count, ALT levels, and positive hepatitis B e antigen result. The model exhibited satisfactory discrimination and calibration, with c-statistics of 0.844 and 0.813 in the derivation and validation cohorts with multiple imputation, respectively. The model yielded a greater positive net benefit compared with other strategies in the 0% to 18% threshold.

LIMITATION

Validation in cohorts of other races and receiving antiviral treatment was lacking.

CONCLUSION

Our new prognostic model, based on the nonlinear association between HBV viral loads and HCC risk, provides a valuable tool for predicting and stratifying HCC risk in noncirrhotic patients with CHB who are not currently indicated for antiviral treatment.

PRIMARY FUNDING SOURCE

Korean government.

Management of antiviral treatment for chronic hepatitis B patients with high viral load

Currently, the therapeutic indications for chronic hepatitis B are expanding, and chronic hepatitis B virus (HBV) infection seemingly has entered the era of "treat-all" or "simplified treatment". In this context, there remain many unresolved issues encompassing aspects like diagnosis, treatment, and disease management. For patients with a high baseline viral load [HBV DNA > 2 × 10⁷ IU/mL according to the Chinese Medical Association guidelines, and > 10⁷ IU/mL according to the European Association for the Study of the Liver guidelines], following the implementation of antiviral treatment, there may exist issues such as a relatively low virological response rate and corresponding increased risks of low level viremia (LLV) and HBV drug resistance mutations. Once patients develop LLV, their liver diseases will continue to progress (including the progression of liver fibrosis, cirrhosis, and hepatocellular carcinoma). In the LLV population, how can we optimize the subsequent treatment strategy (replacement therapy or combination therapy)? What is the modality of combination therapy? How effective is the optimized treatment? Therefore, we must take precautions beforehand and remain vigilant against the potential issues that the new strategy might bring. In this paper, based on the advances in domestic and international research, we discuss the correlation between HBV DNA level and disease progression, the efficacy of antiviral therapy in patients with a high baseline viral load, the epidemiology and disease progression of LLV, and the optimization of treatment strategies for LLV, aiming to provide references for the management of antiviral therapy for hepatitis B patients with a high viral load.

Association of Baseline Hepatitis B Virus DNA and On-Treatment Risk of Cirrhosis and Hepatocellular Carcinoma

Background

Recent studies suggest an inverse relationship between baseline levels of hepatitis B virus (HBV) DNA and on-treatment risk of hepatocellular carcinoma (HCC) in patients with chronic hepatitis B (CHB). However, data are limited to Asian cohorts, and it is unclear if similar associations hold true for non-Asians with CHB. We aimed to evaluate association of baseline HBV DNA with long-term risks of cirrhosis and HCC among a predominantly non-Asian cohort of CHB patients in the USA.

Methods

Using longitudinal data from the national Veterans Affairs database, we evaluated the risk of cirrhosis or HCC among adults with non-cirrhotic CHB who are on continuous antiviral therapy, stratified by moderate levels of baseline HBV DNA (4.00 - 6.99 log10 IU/mL) vs. high levels of baseline HBV DNA (7.00 log10 IU/mL or higher). Propensity score weighting was applied, and competing risks cumulative incidence functions and Cox proportional hazards models were utilized.

Results

Among 1,129 non-cirrhotic CHB patients (41% non-Hispanic White, 36% African American, mean age 57.0 years, 62.2% hepatitis B e antigen (HBeAg) positive), 585 had moderate levels of baseline HBV DNA and 544 had high HBV DNA. After propensity score weighting, no significant difference in risk of cirrhosis was observed between moderate vs. high baseline HBV DNA (4.55 vs. 5.22 per 100 person-years, hazard ratio (HR): 0.87, 95% confidence interval (CI): 0.69 - 1.09, P = 0.22), but risk of HCC was significantly higher in patients with moderate vs. high baseline HBV DNA (0.84 vs. 0.69 per 100 person-years, HR: 1.33, 95% CI: 1.09 - 1.62, P < 0.01).

Conclusions

Among a national cohort of predominantly non-Asian US veterans with non-cirrhotic CHB on antiviral therapy, moderate levels of baseline HBV DNA was associated with higher risk of HCC than high HBV DNA.