KASL clinical practice guidelines for management of chronic hepatitis B

Aetiology of chronic liver disease is a valuable factor for stratifying adverse outcomes of acute decompensation: prospective observational study

BACKGROUND/AIMS

Acute decompensation (AD) is defined as the development of complications related to portal hypertension and liver dysfunction that affect the progression of chronic liver disease (CLD) or liver cirrhosis (LC). Variations exist in patient demographics and prognostic outcomes of AD based on the aetiology of CLD, encompassing LC. However, limited research has been conducted to analyse these discrepancies across aetiologies.

METHODS

The prospective Korean Acute-on-Chronic Liver Failure (KACLiF) cohort consisted of 1,501 patients who were hospitalized with AD of CLD from July 2015 to August 2018. In this study, we assess the clinical attributes and prognostic implications of AD with CLD/LC stratified by the aetiology.

RESULTS

Among 1,501 patients, the mean age was 54.7 years old and 1,118 patients (74.5%) were men. The common events of AD were GI bleeding (35.3%) and jaundice (35.0%). There was a median follow-up of 8.0 months (1.0-16.0 months). The most common aetiology of CLD was alcohol (n = 1021), followed by viral hepatitis (n = 206), viral hepatitis with alcohol-related (n = 129), cryptogenic (n = 108) and autoimmune (n = 37). Viral hepatitis with alcohol-related CLD showed a poor liver function profile and a high frequency of acute-on-chronic liver failure (ACLF) [22.1% vs. 19.6% (alcohol CLD), 8.1% (viral CLD), 5.6% (autoimmune related CLD and 16.0% (cryptogenic CLD)] with worse adverse outcomes (mortality or liver transplantation) than other aetiologies. The difference in aetiology was a significant factor for 28-day adverse outcomes in multivariate analysis even in a high MELD score (≥15), which indicated poor baseline liver function and prognosis (p < 0.001).

CONCLUSION

The aetiology of CLD constitutes a pivotal determinant influencing both short- and long-term adverse outcomes of AD in CLD, even among individuals presenting with elevated MELD scores. Notably, patients afflicted with viral hepatitis should exercise caution even in the consumption of modest quantities of alcohol that induced the exacerbations in the adverse outcomes associated with AD.

Improvement in renal function after switching from entecavir to tenofovir alafenamide in chronic hepatitis B patients with low estimated glomerular filtration rates

INTRODUCTION AND OBJECTIVES

Tenofovir alafenamide (TAF) and entecavir (ETV) are both considered renal-friendly nucleoside/nucleotide analogs (NAs). However, the difference between ETV and TAF in terms of renal function remains unclear. This study aims to compare the renal safety profiles of two antiviral medications directly and evaluate the impact of switching from ETV to TAF treatment on renal function in chronic hepatitis B (CHB) patients with low estimated glomerular filtration rates (eGFR).

PATIENTS AND METHODS

A total of 179 CHB patients who received TAF (n=84) or ETV (n = 95) between 2019 and 2023 were included in the study. Changes in eGFR levels between two treatment groups from baseline to 72 weeks were compared to measure the influence of these NAs on renal function.

RESULTS

At baseline, 84 patients were included in each treatment group after a 1:1 propensity score matching process. At week 48, a notable different changes in eGFR were observed between the two groups. Gender, baseline eGFR, and medication (TAF/ETV) were significantly correlated with eGFR abnormalities. Furthermore, eGFR abnormalities at week 48 led to the transition of 6 patients in the ETV group to TAF. eGFR significantly increased (83.60 ± 5.45 vs. 93.39 ± 9.88 mL/min/1.73 m2; p=0.031) and serum creatinine significantly decreased (81.47±11.36 vs. 74.9±10.67 μmol/L; p=0.046) from week 48 to 60. At week 48, the incidence of low-level viremia (LLV) was 19.0% in the ETV group and 16.7% in the TAF group, respectively (p>0.05). Pairwise comparisons revealed no significant difference in the percentage of LLV between the ETV continued group and the TAF continued group at week 48, 60, and 72. Additionally, there was also no significant difference in the proportion of LLV between the ETV+TAF combination group and the TAF+ETV combination group at week 48, 60, and 72.

CONCLUSIONS

There was a substantial difference in eGFR between ETV and TAF treatments at week 48. Gender, baseline eGFR, and medication (TAF/ETV) were all remarkably positive indicators of eGFR abnormalities. In patients receiving ETV, an early switch to TAF may result in the reversal of early-stage renal damage.

AI model using CT-based imaging biomarkers to predict hepatocellular carcinoma in patients with chronic hepatitis B

BACKGROUND & AIMS

Various hepatocellular carcinoma (HCC) prediction models have been proposed for patients with chronic hepatitis B (CHB) using clinical variables. We aimed to develop an artificial intelligence (AI)-based HCC prediction model by incorporating imaging biomarkers derived from abdominal computed tomography (CT) images along with clinical variables.

METHODS

An AI prediction model employing a gradient-boosting machine algorithm was developed utilizing imaging biomarkers extracted by DeepFore, a deep learning-based CT auto-segmentation software. The derivation cohort (n = 5,585) was randomly divided into the training and internal validation sets at a 3:1 ratio. The external validation cohort included 2,883 patients. Six imaging biomarkers (i.e. abdominal visceral fat-total fat volume ratio, total fat-trunk volume ratio, spleen volume, liver volume, liver-spleen Hounsfield unit ratio, and muscle Hounsfield unit) and eight clinical variables were selected as the main variables of our model, PLAN-B-DF.

RESULTS

In the internal validation set (median follow-up duration = 7.4 years), PLAN-B-DF demonstrated an excellent predictive performance with a c-index of 0.91 and good calibration function (p = 0.78 by the Hosmer-Lemeshow test). In the external validation cohort (median follow-up duration = 4.6 years), PLAN-B-DF showed a significantly better discrimination function compared to previous models, including PLAN-B, PAGE-B, modified PAGE-B, and CU-HCC (c-index, 0.89 vs. 0.65-0.78; all p <0.001), and maintained a good calibration function (p = 0.42 by the Hosmer-Lemeshow test). When patients were classified into four groups according to the risk probability calculated by PLAN-B-DF, the 10-year cumulative HCC incidence was 0.0%, 0.4%, 16.0%, and 46.2% in the minimal-, low-, intermediate-, and high-risk groups, respectively.

CONCLUSION

This AI prediction model, integrating deep learning-based auto-segmentation of CT images, offers improved performance in predicting HCC risk among patients with CHB compared to previous models.

IMPACT AND IMPLICATIONS

The novel predictive model PLAN-B-DF, employing an automated computed tomography segmentation algorithm, significantly improves predictive accuracy and risk stratification for hepatocellular carcinoma in patients with chronic hepatitis B (CHB). Using a gradient-boosting algorithm and computed tomography metrics, such as visceral fat volume and myosteatosis, PLAN-B-DF outperforms previous models based solely on clinical and demographic data. This model not only shows a higher c-index compared to previous models, but also effectively classifies patients with CHB into different risk groups. This model uses machine learning to analyze the complex relationships among various risk factors contributing to hepatocellular carcinoma occurrence, thereby enabling more personalized surveillance for patients with CHB.

Risk of HBV reactivation in HBV/HCV-co-infected HCV-treated patients: A single-center study

Hepatitis B virus (HBV) reactivation in patients with HBV/hepatitis C virus (HCV) co-infection due to direct-acting antiviral agent (DAA) therapy is a growing concern. This study focused on 47 patients with chronic hepatitis C (CHC) and positivity for HBV surface antigen (HBsAg) who were treated with interferon (IFN)-based therapy, DAA, or DAA after IFN-based therapy failure and followed for a median of 53 months. Here, we aimed to determine HBV reactivation rates and associated factors, the incidence of HBV and liver-related events, and the rate of sustained virologic response (SVR) for HCV. Fifteen (15/47, 31.9%) patients experienced HBV reactivation during or after HCV treatment. This reactivation occurred significantly more frequently in patients who received DAA treatment after IFN-based treatment failure than in those who received IFN-based treatment (IFN-based vs. DAA vs. DAA treatment after IFN-based treatment failure 11.8% vs. 35.3% vs. 53.8%, respectively; p = 0.046). The interval from HCV treatment initiation to HBV reactivation was shortest in the DAA group (4.2 months), followed by the DAA after IFN-based treatment failure group (6.4 months) and the IFN-based treatment group (44.5 months) (p < 0.001). One case of HBV-related hepatitis spontaneously resolved after 4 weeks. The rate of SVR for the entire cohort was 87.2%, with no significant difference in this regard among the IFN-based treated, DAA-treated, and DAA-treated after IFN-based treatment failure arms at 82.4%, 88.2%, and 92.3%, respectively. HBV reactivation in HBsAg-positive CHC patients is more common and occurs earlier in those who receive DAA treatment after IFN-based treatment failure than in those with IFN-based treatment. Therefore, all patients with CHC should be tested for HBV exposure prior to DAA treatment. In addition, HBsAg positive patients, especially those among whom have previously experienced IFN-based treatment failure, should be closely monitored for HBV reactivation during DAA therapy.

A greater frequency of circulating CCR7loPD-1hi follicular helper T cells indicates a durable clinical cure after Peg IFN-α therapy in chronic hepatitis B patients

BACKGROUND

Emerging evidence indicates that the treatment duration of pegylated interferon-α and HBsAb may predict relapse in chronic hepatitis B (CHB) patients who achieved clinical cure. However, the host immunological mechanisms contributing to clinical relapse remain poorly characterized.

OBJECTIVES

This study aimed to identify the immunological factors associated with relapse in chronic hepatitis B (CHB) patients who achieved clinical cure based on pegylated interferon-alpha treatment.

METHODS

CHB patients who achieved HBsAg loss after discontinuing pegylated interferon-alpha therapy were enrolled and followed up for at least 96 weeks. HBcrAg and immunological markers, including the proportion of follicular helper T (Tfh) cells were assessed by flow cytometry. Peripheral blood cytokine levels were measured using a Luminex assay. The primary outcome was the correlation between immunological markers with relapse at the end of treatment (EOT) and end of follow-up (EOF).

RESULTS

A total of 456 CHB patients were included. During the 96-week follow-up period, 37 patients (8.11%) experienced a relapse. Propensity score matching was performed at a 1:2 ratio, resulting in the inclusion of 37 relapsed (R) and 74 non-relapsed (NR) patients. The NR group exhibited higher proportions of Tfh cells than the R group in both EOT and EOF (EOT: 12.52% vs. 8.78%, p=0.008; EOF: 11.38% vs. 8.29%, p=0.008). A significantly greater proportion of CCR7loPD-1hi Tfh cells was observed in the NR group at the EOT (9.4% vs. 4.5%, p=0.009). The frequency of CCR7loPD-1hi Tfh cells was significantly and positively correlated with anti-HB levels in EOT (p=0.015, r=0.392). Serum levels (median, pg/mL) of CTLA-4 (EOT: 14.87 vs. 7.84; EOF: 14.87 vs. 7.97), PD-1 (EOT: 321.44 vs. 203.96; EOF: 288.45 vs. 166.04), and TIM-3 (EOT:4487 vs. 21254; EOF:2973 vs. 1768) were significantly higher in the R group than in the NR group at both EOT and EOF (p<0.05). At EOT, the HBcrAg level was significantly greater in the R than in the NR group (3.45±0.94 vs. 2.63±0.80 log10 U/mL, p=0.003).

CONCLUSIONS

Higher frequencies of CCR7loPD-1hi Tfh cells, lower levels of sCTLA-4 as well as sPD-1 in EOT were protective factors for relapse among CHB patients who experienced HBsAg loss after pegylated interferon-alpha therapy. CCR7loPD-1hiTfh cells produced insufficient IL-21 in patients who experienced recurrent disease, which resulted in a decrease in the ability of B cells to produce anti-HBs.

Association of nucleos(t)ide analogue therapy with Parkinson disease in chronic hepatitis B patients

Prolonged therapy using nucleos(t)ide analogs (NUC) is inevitable in patients with chronic hepatitis B (CHB) infection, but its long-term impact on Parkinson's disease (PD) risk remains unclear. This study evaluated the association between NUC therapy and PD incidence in a nationwide CHB cohort. The study population comprised the National Health Insurance Service claims database from January 1, 2013, to December 31, 2013, only included treatment naïve CHB patients and those without previously diagnosed with PD. Participants were followed until PD diagnosis or study completion. The primary outcome was PD incidence, comparing patients who initiated NUC therapy at cohort entry with those who did not. Over the 7.9-year study period, the incidence rate of PD in NUC-treated patients was 1.48 per 1000 persons, compared to 1.95 per 1000 persons in the untreated group. In an adjusted competing risk model, the 3-year follow-up showed a statistically significant reduction in risk (hazard ratio [HR]: 0.61; 95% confidence interval [CI] 0.39-0.97). In the propensity score-matched cohort of 18,365 pairs, the cumulative incidence during 2-4 years of follow-up was significantly lower in the NUC-treated group compared to the untreated group. However, no statistically significant difference in cumulative PD incidence was observed between the groups at the early or late stages of the follow-up period. NUC therapy initially reduced PD incidence, but this protective effect diminished over time, indicating a time-varying effect. Regular PD screening may be needed for long-term NUC users.

Head-to-Head Comparison of Long-Term HCC Risk of Antivirals-Treated Versus Untreated Low-Level Viremia in HBV-Compensated Cirrhosis

BACKGROUND

Among patients with hepatitis B virus (HBV)-infected compensated cirrhosis and low-level viremia, there are limited data for comparative outcomes between those treated with oral nucleos(t)ide analogs versus those not. We conducted a large, multi-ethnic, multi-center study to examine the impact of antiviral treatment (AVT) on long-term hepatocellular carcinoma (HCC) risk for compensated cirrhosis and low-level viremia.

METHODS

Patients with compensated cirrhosis and low-level viremia (serum HBV-DNA 20-2000 IU/mL) at baseline or before AVT were screened for eligibility from 19 hospitals in South Korea, Singapore, and Japan. The primary outcome was HCC development, compared between those receiving AVT versus those untreated throughout follow-up.

RESULTS

Among 848 patients (mean age 55.7 years and 66.9% male), AVT (n = 233) was associated with significantly lower annual HCC incidence compared to non-AVT (n = 615); 1.72/100 versus 2.99/100 person-years (PY), respectively (p = 0.033). Multivariable Cox-regression analyses determined that AVT was associated with significantly lower HCC risk, compared to non-AVT (adjusted HR [HR] 0.514, 95% confidence interval [CI] 0.271-0.976; p = 0.042). In a landmark analysis, HCC incidence was similar between two groups until 18 months, but after this landmark, the treated group had the significantly lower HCC risk compared to untreated group (p = 0.012). Furthermore, propensity score-matching analysis consistently showed that AVT was associated with significantly lower HCC risk, compared to non-AVT; the annual HCC incidence of 1.45/100 PYs versus 2.73/100 PY, respectively (p = 0.043).

CONCLUSIONS

Patients with compensated cirrhosis and low-level viremia may benefit from long-term AVT, highlighting appropriate amendment of reimbursement guidelines.

Risk of Hepatocellular Carcinoma Decreases After Antiviral Therapy-Induced HBsAg Seroclearance

BACKGROUND

Antiviral therapy (AVT) reduces the risk of hepatitis B virus-related hepatocellular carcinoma (HCC).

AIMS

The difference in risk of HCC after hepatitis B surface antigen (HBsAg) seroclearance to the AVT status was explored.

METHODS

Patients with chronic hepatitis B who achieved HBsAg seroclearance were retrospectively evaluated. The primary outcome was the development of HCC after HBsAg seroclearance.

RESULTS

Of the study population, 1280 (84.2%) and 241 (15.8%) patients achieved HBsAg seroclearance without (spontaneous clearance group) and with AVT (AVT-induced clearance group), respectively. HCC cumulative incidence was comparable between the two groups (hazard ratio [HR] = 0.461; log-rank test, p = 0.197), whereas it was significantly lower in the AVT-induced HBsAg clearance group than in the spontaneous HBsAg clearance group in inverse probability of treatment weighting analysis (HR = 0.442; log-rank test, p = 0.004). In multivariate analysis, spontaneous HBsAg clearance, albumin-bilirubin (ALBI) grade ≥ 2, cirrhosis, and platelet count < 50 × 109/L were independently associated with the increased risk of HCC. The newly established antiviral therapy, cirrhosis, ALBI, and platelet count (ACAP) scores had a C-index of 0.765, and the time-dependent areas under the curve of HCC prediction at 5 and 8 years were 0774 and 0.823, respectively.

CONCLUSION

The risk of HCC differed according to the AVT status after HBsAg seroclearance.

Impact of nucleos(t)ide analogue therapy on the incidence of Alzheimer's disease in patients with chronic hepatitis B virus infection

BACKGROUND

Long-term therapy with nucleos(t)ide analogs (NUCs) is inevitable for chronic hepatitis B (CHB) patients. However, how NUC therapy on the developing Alzheimer's disease (AD) in these patients remains controversial.

METHODS

This retrospective cohort study used the Korean National Health Insurance Service claims database from January 1, 2013, to December 31, 2013, treatment naïve CHB patients and those without previously diagnosed with AD. Participants were followed from the index date until either the diagnosis of AD or the study's conclusion on December 31, 2021. The primary outcome was the incidence of AD, compared between the group with initiated NUC therapy (n = 18,365) at cohort entry and the group without NUC therapy (n = 212,820).

RESULTS

During the study, 416 patients were diagnosed with AD. After propensity-score matching (18,365 pairs), the 5- to 7-year follow-up showed a significantly lower hazard ratio (HR) in the NUC-treated group compared to the untreated group (HR 0.31-0.40), with HRs remaining constant over time. Subgroup analysis showed more pronounced benefits of NUC therapy in patients under 65 years (HRs: 0.22 vs. 1.23; P < 0.05) and those without dyslipidemia (HRs: 0.14 vs. 1.09; P < 0.05). Protective effects were also observed across subgroups with hypertension, chronic kidney disease, heart disease, and a history of brain trauma, consistent with AD risk factor trends.

CONCLUSIONS

Our study analyses suggest that NUC therapy appears to have a protective effect against the development of AD in patients with CHB.

Machine Learning-Based Model Used for Predicting the Risk of Hepatocellular Carcinoma in Patients with Chronic Hepatitis B

Object

Currently, predictive models that effectively stratify the risk levels for hepatocellular carcinoma (HCC) are insufficient. Our study aimed to assess the 10-year cumulative risk of HCC among patients suffering from chronic hepatitis B (CHB) by employing an artificial neural network (ANN).

Methods

This research involved 1717 patients admitted to Beijing Ditan Hospital of Capital Medical University and the People's Liberation Army Fifth Medical Center. The training group included 1309 individuals from Beijing Ditan Hospital of Capital Medical University, whereas the validation group contained 408 individuals from the People's Liberation Army Fifth Medical Center. By performing a univariate analysis, we pinpointed factors that had an independent impact on the development of HCC, which were subsequently employed to create the ANN model. To evaluate the ANN model, we analyzed its predictive accuracy, discriminative performance, and clinical net benefit through measures including the area under the receiver operating characteristic curve (AUC), concordance index (C-index), and calibration curves.

Results

The cumulative incidence rates of HCC over a decade were observed to be 3.59% in the training cohort and 4.41% in the validation cohort. We incorporated nine distinct independent risk factors into the ANN model's development. Notably, in the training group, the area under the receiver operating characteristic (AUROC) curve for the ANN model was reported as 0.929 (95% CI 0.910-0.948), and the C-index was 0.917 (95% CI 0.907-0.927). These results were significantly superior to those of the mREACHE-B(0.700, 95% CI 0.639-0.761), mPAGE-B(0.800, 95% CI 0.757-0.844), HCC-RESCUE(0.787, 95% CI 0.732-0.837), CAMD(0.760, 95% CI 0.708-0.812), REAL-B(0.767, 95% CI 0.719-0.816), and PAGE-B(0.760, 95% CI 0.712-0.808) models (p < 0.001). The ANN model proficiently categorized patients into low-risk and high-risk groups based on their 10-year projections. In the training cohort, the positive predictive value (PPV) for the incidence of liver cancer in low-risk individuals was 92.5% (95% CI 0.921-0.939), whereas the negative predictive value (NPV) stood at 88.2% (95% CI 0.870-0.894). Among high-risk patients, the PPV reached 94.6% (95% CI 0.936-0.956) and the NPV was 90.2% (95% CI 0.897-0.917). These results were also confirmed in the independent validation cohort.

Conclusion

The model utilizing artificial neural networks demonstrates strong performance in personalized predictions and could assist in assessing the likelihood of a 10-year risk of HCC in patients suffering from CHB.

A Machine Learning Model to Predict De Novo Hepatocellular Carcinoma Beyond Year 5 of Antiviral Therapy in Patients With Chronic Hepatitis B

BACKGROUND AND AIMS

This study aims to develop and validate a machine learning (ML) model predicting hepatocellular carcinoma (HCC) in chronic hepatitis B (CHB) patients after the first 5 years of entecavir (ETV) or tenofovir (TFV) therapy.

METHODS

CHB patients treated with ETV/TFV for > 5 years and not diagnosed with HCC during the first 5 years of therapy were selected from two hospitals. We used 36 variables, including baseline characteristics (age, sex, cirrhosis, and type of antiviral agent) and laboratory values (at baseline, at 5 years, and changes between 5 years) for model development. Five machine learning algorithms were applied to the training dataset and internally validated using a test dataset. External validation was performed.

RESULTS

In years 5-15, a total of 279/5908 (4.7%) and 25/562 (4.5%) patients developed HCC in the derivation and external validation cohorts, respectively. In the training dataset (n = 4726), logistic regression showed the highest area under the receiver operating curve (AUC) of 0.803 and a balanced accuracy of 0.735, outperforming other ML algorithms. An ensemble model combining logistic regression and random forest performed best (AUC, 0.811 and balanced accuracy, 0.754). The results from the test dataset (n = 1182) verified the good performance of the ensemble model (AUC, 0.784 and balanced accuracy, 0.712). External validation confirmed the predictive accuracy of our ensemble model (AUC, 0.862 and balanced accuracy, 0.771). A web-based calculator was developed (http://ai-wm.khu.ac.kr/HCC/).

CONCLUSIONS

The proposed ML model excellently predicted HCC risk beyond year 5 of ETV/TFV therapy and, therefore, could facilitate individualised HCC surveillance based on risk stratification.

Impact of Maternal Hepatitis B Virus Infection on Congenital Heart Disease Risk in Offspring: A National Cohort Study

Maternal hepatitis B virus (HBV) infection influence both maternal and fetal health. Recent studies reported increased congenital anomalies in offspring of HBV-infected mothers. This study investigated whether maternal HBV infection was associated with higher risk of congenital heart disease (CHD) in children. With the Korean National Health Insurance Service (K-NHIS) database, this retrospective cohort study included live births from 2005 to 2019, born to women under 40. Propensity score matching with a 1:3 ratio was conducted to compare HBV-infected mother's children with HBV-uninfected mother's children while adjusting for various maternal and pregnancy-related factors. Logistic regression models were used to estimate the risk. Of 2,673,059 eligible participants, 263,904 children were born to HBV-infected mothers. Risk estimation in this group showed a modestly increased risk of CHD (OR = 1.05, 95% CI = 1.02, 1.09). Notably, when pregnant mothers were treated with antiviral medication, there was an indication of reduced CHD risk, although this result was not statistically significant. The highest risk of CHD was observed in children who were themselves infected with HBV. The study indicates an association between maternal HBV infection and an increased CHD risk in offspring. The findings suggest the need to re-evaluate the timing of antiviral treatment during pregnancy to align more closely with early stages of fetal cardiac development. Further research is needed to understand the biological mechanisms of this association and to redefine clinical guidelines for managing HBV infection in pregnancy.

Unraveling Demographic Patterns in Hepatitis B Clinical and Laboratory Profiles: Insights From a Ghanaian Cohort: A Retrospective Study

Background and Aims

The influence of age and gender on the manifestations of Hepatitis B (HB) disease is underexplored and yields varied findings. This study assessed the impact of age and gender on HB disease manifestations in a Ghanaian population.

Methods

This retrospective study evaluated 569 patients at Tamale Teaching Hospital. Disease manifestations were compared separately between male and female patients across different age groups and among four distinct age groups within male and female patients.

Results

It revealed a male-to-female ratio of 5.1:1, with significant differences observed among age categories. HBsAg was significantly more prevalent in adult males (p < 0.05), while polydipsia showed equal prevalence between genders (p < 0.05). Female adults exhibited higher rates of constipation and palpitation compared to males (p < 0.05). In older patients, females had higher ALT and HBeAg prevalence than males (p < 0.05). Disease manifestation did not significantly differ by gender among children and younger patients (p > 0.05). Among males, viral load differed significantly across age groups and correlated positively with age (p < 0.05). Females showed positive correlations of jaundice, HBeAg, low globulin, and high AST with age (p < 0.05), but nausea was negatively correlated (p < 0.05).

Conclusion

This study highlights unique clinical and laboratory features in reproductive-aged female HB patients.

Comparison of hepatocellular carcinoma incidence after long-term treatment with besifovir vs. tenofovir AF

Besifovir dipivoxil maleate (BSV) is a novel antiviral agent widely used in South Korea for treating chronic hepatitis B (CHB). This study aimed to compare the incidence of hepatocellular carcinoma (HCC) following long-term use of BSV versus tenofovir alafenamide fumarate (TAF), utilizing large-scale national data. A total of 41,949 patients were analyzed, with propensity score matching (PSM) yielding 2,239 BSV and 6,717 TAF patients. The HCC incidence rate per 1,000 person-years was 1.8 for BSV versus 2.4 for TAF before matching (P = 0.057) and 1.6 versus 2.2 after matching (P = 0.284). Multivariate Cox regression identified age, male sex, antiviral duration, Charlson Comorbidity Index (CCI) score, and decompensated cirrhosis as significant risk factors for HCC, while antiviral type was not (HR 1.12, P = 0.413). Subgroup analyses showed no significant differences in HCC incidence between BSV and TAF in cirrhotic or non-cirrhotic patients. These findings suggest that BSV offers comparable efficacy to TAF in preventing HCC and is a promising option for CHB management. Longer-term studies with larger cohorts are necessary to confirm these results and assess the full impact of BSV on HCC prevention.

Accelerating the momentum to achieve global elimination of hepatitis B infection: a scoping review of hepatitis B guidelines to reduce mother to child transmission

Progress towards achieving global elimination of hepatitis B virus (HBV) by 2030 remains unsatisfactory. Prevention of mother to child transmission is crucial but current Clinical Practice Guidelines (CPGs) gave diverse recommendations, creating confusion and leading to significant challenges in the practical implementation across various regions owing to global inequity. We reviewed 47 CPGs on the management of hepatitis B during pregnancy against twelve important clinical questions. Of 47 guidelines, 80.9% (38/47) supported the universal approach to HBV screening. To select women for antiviral prophylaxis, 78.7% (37/47) recommended the use of HBV DNA levels, while 31.9% (15/47) recommended the use of HBeAg. Of 37 guidelines recommending HBV DNA levels, 94.6% (35/37) recommended a viral load threshold of >200,000 IU/mL to initiate antiviral prophylaxis. Of 16 guidelines addressing the mode of delivery, 87.5% (14/16) encouraged vaginal birth. Of 30 guidelines addressing breastfeeding, 60% (18/30) recommended breastfeeding. However, controversies were found in the optimal timing of HBV disease evaluation during pregnancy and the ideal timing to stop antiviral prophylaxis after delivery. Of 36 guidelines addressing the timing to initiate antiviral prophylaxis, 25% (9/36) advised starting prophylaxis between 24 and 28 weeks, while 75% (27/36) suggested other timings or provided vague descriptions. Of 38 guidelines addressing birth-dose vaccination, 42% (16/38) emphasized the importance of "vaccination as soon as possible after birth." These deficiencies and discrepancies among CPGs could significantly impede global HBV elimination.

The sV184A Variant in HBsAg Specific to HBV Subgenotype C2 Leads to Enhanced Viral Replication and Apoptotic Cell Death Induced by PERK-eIF2α-CHOP-Mediated ER Stress

HBV genotype C, particularly subgenotype C2, is associated with an elevated risk of HCC and aggressive disease activity. We previously identified a nonsynonymous sV184A variant in the HBsAg region, predominantly in HBV subgenotype C2. This study investigates the mechanistic role of the sV184A variant in promoting liver disease progression. Analysis of 109 chronically HBV-infected patients revealed that the sV184A variant correlates with significantly elevated HBV DNA. Both patient data and public database indicated that sV184A is associated with high frequency of BCP mutations, however, the high HBV DNA in the sV184A group are independent of the presence of BCP mutations. In vitro and in vivo studies demonstrated that the sV184A variant enhances HBV replication and induces ER stress via the PERK-eIF2α-CHOP pathway, leading to apoptosis. HBV large surface (LHB)(LHB) protein was found to be a key factor, responsible for the strong ER stress, as the sV184A variant increases LHB protein stability. Pharmacological inhibition of PERK signaling or mutation of the LHB mitigated HBV proliferation and apoptosis induced by the sV184A variant. The sV184A variant specific to HBV subgenotype C2 significantly promotes HBV replication and apoptosis, serving as a driver of advanced liver disease and potentially increasing mutation rates in affected patients.

A machine learning model to predict liver-related outcomes after the functional cure of chronic hepatitis B

BACKGROUND & AIMS

The risk of hepatocellular carcinoma (HCC) and hepatic decompensation persists after hepatitis B surface antigen (HBsAg) seroclearance. This study aimed to develop and validate a machine learning model to predict the risk of liver-related outcomes (LROs) following HBsAg seroclearance.

METHODS

A total of 4,787 consecutive patients who achieved HBsAg seroclearance between 2000 and 2022 were enrolled from six centers in South Korea and a territory-wide database in Hong Kong, comprising the training (n = 944), internal validation (n = 1,102), and external validation (n = 2,741) cohorts. Three machine learning-based models were developed and compared in each cohort. The primary outcome was the development of any LRO, including HCC, decompensation, and liver-related death.

RESULTS

During a median follow-up of 55.2 (IQR 30.1-92.3) months, 123 LROs were confirmed (1.1%/person-year) in the Korean cohort. The model with the best predictive performance in the training cohort was selected as the final model (designated as PLAN-B-CURE), which was constructed using a gradient boosting algorithm and seven variables (age, sex, diabetes, alcohol consumption, cirrhosis, albumin, and platelet count). Compared to previous HCC prediction models, PLAN-B-CURE showed significantly superior accuracy in the training cohort (c-index: 0.82 vs. 0.63-0.70, all p <0.001; area under the receiver-operating characteristic curve: 0.86 vs. 0.62-0.72, all p <0.01; area under the precision-recall curve: 0.53 vs. 0.13-0.29, all p <0.01). PLAN-B-CURE showed a reliable calibration function (Hosmer-Lemeshow test p >0.05) and these results were reproduced in the internal and external validation cohorts.

CONCLUSION

This novel machine learning model consisting of seven variables provides reliable risk prediction of LROs after HBsAg seroclearance that can be used for personalized surveillance.

IMPACT AND IMPLICATIONS

Using large-scale multinational data, we developed a machine learning model to predict the risk of liver-related outcomes (i.e., hepatocellular carcinoma, decompensation, and liver-related death) after the functional cure of chronic hepatitis B (CHB). The new model named PLAN-B-CURE was constructed using seven variables (age, sex, alcohol consumption, diabetes, cirrhosis, serum albumin, and platelet count) and a gradient boosting machine algorithm, and it demonstrated significantly better predictive accuracy than previous models in both the training and validation cohorts. The inclusion of diabetes and significant alcohol intake as model inputs suggests the importance of metabolic risk factor management after the functional cure of CHB. Using seven readily available clinical factors, PLAN-B-CURE, the first machine learning-based model for risk prediction after the functional cure of CHB, may serve as a basis for individualized risk stratification.

Effect of invasive tests during pregnancy on perinatal transmission of hepatitis B infection: a scoping review

Prenatal and intrapartum invasive tests are possible mechanisms of mother to child transmission (MTCT) of hepatitis B virus (HBV). The viral activity can affect the MTCT risk after invasive tests, but the evidence is scarce. This scoping review discussed the effects of prenatal or intrapartum invasive tests on the risk of HBV MTCT. The risk of MTCT after amniocentesis was low among hepatitis B infected pregnant individuals with negative hepatitis B e antigen (HBeAg) statuses or HBV DNA < 7 log10 IU/mL, and comparable to those that did not undergo prenatal invasive tests. Amniocentesis could increase the risk of MTCT among women with seropositive HBeAg statuses or HBV DNA ≥ 7 log10 IU/mL, but there were no MTCT among these women who received antiviral treatment. Data on CVS, cordocentesis and intrapartum invasive tests were insufficient to conclude their effects on MTCT. We also reviewed 50 international clinical practice guidelines. Most of them did not have recommendations on the management of hepatitis B infected pregnant individuals requiring prenatal or intrapartum invasive tests and significant discrepancies existed among the remaining guidelines. A workflow and two pragmatic approaches were discussed to assist clinical management. Furthermore, we would like to encourage future research to provide comprehensive data on the factors influencing the MTCT rate (such as maternal HBV DNA viral load and HBeAg status, availability and timing of neonatal birth dose immunizations, transplacental or transamniotic invasive tests, complications of the invasive tests and the use of antiviral prophylaxis).

Tenofovir Disoproxil Fumarate Versus Entecavir: Effects on Lipid Profiles and Cardiovascular Outcomes in People Living With Chronic Hepatitis B

While entecavir (ETV) and tenofovir disoproxil fumarate (TDF) effectively manage chronic hepatitis B, their long-term effects on lipid metabolism and cardiovascular outcomes remain unclear. This study compares the impact of ETV, TDF, and treatment-naïve (control group) on hyperlipidemia and major adverse cardiac events (MACE) in people living with chronic hepatitis B (PLWHB). We used claim data from the South Korean National Health Insurance Service. Propensity score matching was used to account for confounding factors. The 5-year cumulative incidence of dyslipidemia was 7.10% for TDF, 12.17% for ETV, and 18.55% for the control group, with incidence rates per 1000 person-years of 14.5, 25.5, and 38.9, respectively. TDF showed a significantly lower risk of dyslipidemia compared to ETV (IRR: 0.56, p < 0.001) and the control group, which was confirmed in Cox regression analysis (HR: 0.392 vs. control, p < 0.001). For MACE, the 5-year cumulative incidence was 9.11% for TDF, 10.98% for ETV, and 12.32% for the control group, with incidence rates per 1000 person-years of 18.4, 22.5, and 24.8, respectively. TDF demonstrated a reduced risk compared to ETV (IRR: 0.817, p < 0.001), which was similarly supported by Cox regression analysis (HR: 0.728 vs. control, p < 0.001). In conclusion, TDF not only reduces the risk of hyperlipidemia but is also associated with a reduced risk of MACE compared to ETV or treatment-naive group in PLWHB.

Optimal tacrolimus levels for reducing CKD risk and the impact of intrapatient variability on CKD and ESRD development following liver transplantation

BACKGROUND/AIMS

This study aimed to identify the risk factors for chronic kidney disease (CKD) and end-stage renal disease (ESRD) following liver transplantation (LT), with a specific focus on tacrolimus levels and intrapatient variability (IPV).

METHODS

Among the 1,076 patients who underwent LT between 2000 and 2018, 952 were included in the analysis. The tacrolimus doses and levels were recorded every 3 months, and the IPV was calculated using the coefficient of variability. The cumulative incidence rates of CKD and ESRD were calculated based on baseline kidney function at the time of LT. The impact of tacrolimus levels and their IPV on the development of CKD and ESRD was evaluated, and the significant risk factors were identified.

RESULTS

Within a median follow-up of 97.3 months, the 5-year cumulative incidence rates of CKD (0.58 vs. 0.24) and ESRD (0.07 vs. 0.01) were significantly higher in the acute kidney injury group than in the normal glomerular filtration rate (GFR) group. In the normal GFR group, the tacrolimus levels were identified as a risk factor for CKD, with a level of ≤4.5 ng/mL suggested as optimal for minimizing the risk of CKD. Furthermore, the IPV of tacrolimus levels and doses emerged as a significant risk factor for CKD development in both groups (p<0.05), with tenofovir disoproxil fumarate also being a risk factor in HBV-infected patients. The IPV of tacrolimus levels was also a significant factor in ESRD development (p<0.05).

CONCLUSION

This study elucidated the optimal tacrolimus trough level and highlighted the impact of IPV on the CKD and ESRD development post-LT.

Treatment decisions based on HBV DNA

The most common cause of hepatocellular carcinoma (HCC) worldwide is chronic hepatitis B virus (HBV) infection (CHB). Long-term suppression of HBV replication by antiviral treatment reduces the risk of HCC and mortality. Nonetheless, only 2.2% of CHB patients globally received the treatment in 2019. Current international CHB guidelines recommend antiviral treatment only in subsets of patients with clear evidence of liver damage as evidenced by elevation of alanine aminotransferase (ALT). This review aims to provide existing evidence that the risk of HCC is significantly associated with serum levels of HBV DNA, and the association is non-linear parabolic, in both untreated and treated CHB patients, regardless of HBeAg status or ALT levels. Therefore, the decision for the antiviral treatment should be based on serum HBV DNA levels and age, rather than ALT levels or liver biopsy, to reduce or prevent the risk of HCC in CHB patients. The potential impact and cost-effectiveness data on early antiviral treatment initiation were also collated.

Association of Hepatitis B Surface Antigen Levels With Long-Term Complications in Chronic Hepatitis B Virus Infection: A Systematic Literature Review

Chronic hepatitis B virus (HBV) infection is a global issue and can lead to cirrhosis and hepatocellular carcinoma (HCC). Hepatitis B surface antigen (HBsAg) is an important marker of HBV infection and HBsAg quantification could be a useful tool in clinical practice. This systematic literature review aimed to explore the association between HBsAg titres and long-term disease outcomes and evaluate the relationship between HBsAg titres, or changes in HBsAg titres, and clinical and treatment characteristics in patients with chronic HBV infection. Structured searches were performed in MEDLINE and Embase (January 2000 to 31 March 2023). Eighty-two studies were included, comprising 51% retrospective cohort studies, mostly conducted in Asia (85%). HBsAg levels were shown to predict the long-term development of cirrhosis and HCC in patients who were untreated prior to and during follow-up; however, these data were inconclusive in mixed and treated populations. HBsAg titres were significantly associated with various virological markers including serum HBV DNA, HBcrAg, HBeAg, HBV RNA levels, intrahepatic covalently closed circular DNA (cccDNA) and intrahepatic HBsAg expression. HBsAg titres generally declined over time; this decline was more pronounced in early (HBeAg-positive) than later disease phases (HBeAg-negative). Higher decline in HBsAg levels was consistently associated with subsequent HBsAg seroclearance and a greater decline in total intrahepatic HBV DNA and cccDNA levels. In conclusion, this review showed that HBsAg levels and rates of decline could inform assessment, management and prediction of outcomes in chronic HBV infection. Further studies in broader, more diverse populations and treated patients are needed.

Hepatitis B surface antigen loss in chronic hepatitis B patients with low-viral-load

BACKGROUND AND AIM

Among low viral load (DNA of hepatitis B virus (HBV) was < 2000 IU/mL), the factor of the loss of hepatitis B surface antigen (HBsAg) remained elusive.

METHODS

The retrospective study recruited patients with chronic hepatitis B (CHB) who were negative low for hepatitis B e-antigen (HBeAg), had a low viral load, and experienced HBsAg loss during follow-up. CHB patients with low-viral load but without consequent HBsAg loss were also enrolled at the ratio of 1:4. The factors contributing to HBsAg loss were analyzed.

RESULTS

A total of 80 patients were recruited for the current study, with a mean age of 63.9 years and 61.3% being male. Among them, 62.5% patients (50/80) were treated with potent nucleoside/nucleotide analogues (NAs) during the follow-up period. Additionally, 12.5% patients (10/80) had a prior history of NAs treatment before enrolment. During the follow-up, HBsAg loss occurred in 17 patients (21.3%). Compared with patients without HBsAg loss, those with HBsAg loss were younger (57.9 years vs 65.5 years; P = 0.01), had lower HBV DNA levels (1.3 log10 IU/mL vs 2.3 log10 IU/mL; P = 0.003), and higher proportion of prior NAs-treated history. Logistic regression analysis revealed that the factors associated with factors associated with HBsAg loss were age < 60 years (OR/CI: 3.95/1.15-13.60, P = 0.03), prior NAs-treated history (OR/CI: 7.59/1.42-40.51, P = 0.01) and current NAs-treated (OR/CI: 0.19/0.05-0.71, P = 0.01).

CONCLUSIONS

In the study, older age and prior NAs were positively associated with HBsAg loss, and current NAs was negatively associated with HBsAg loss. Additionally, some patients experienced HBsAg loss during the NAs therapy.

Effect of renin-angiotensin system inhibitor in incident cancer among chronic hepatitis B patients: An emulated target trial using a nationwide cohort

Background

Although the renin-angiotensin system (RAS) has been reported to be associated with cancer development, the anticancer effects of RAS inhibitors (RASi) remain controversial.

Objectives

This study aimed to investigate the effect of RASi use on cancer incidence in chronic hepatitis B (CHB) patients.

Design

We designed a series of pragmatic trials for each week and followed the patients until the cancer diagnosis, death, or end of follow-up.

Methods

We analyzed CHB patients aged 40–84 years from the nationwide database between 2009 and 2017. We used 3:1 propensity score matching.

Results

Among 15,477 RASi non-users and 5263 RASi users, 2002 developed cancer. The adjusted hazard ratio (HR) for all cancer in RASi users was 0.89 [95% confidence interval (CI): 0.81–0.99]. The adjusted HR (95% CI) of hepatocellular carcinoma (HCC) and extrahepatic cancer were 0.79 (0.65–0.96) and 0.93 (0.82–1.04), respectively. When RASi was further divided, the adjusted HR (95% CI) for cancer of the angiotensin-converting enzyme inhibitor user and the angiotensin II receptor blocker user were 0.66 (0.50–0.87) and 0.93 (0.84–1.03), respectively.

Conclusion

RASi use was associated with a decreased incidence of all cancers, particularly HCC, in CHB patients, suggesting a chemopreventive effect of RASi in this population.

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.

Differential HBV replicative markers and covalently closed circular DNA transcription in immune-active chronic hepatitis B with and without HBeAg

BACKGROUND AND AIMS

Molecular processes driving immune-active chronic hepatitis B (CHB) with and without hepatitis B e antigen (HBeAg) remain incompletely understood. This study aimed to investigate expression profiles of serum and intrahepatic HBV markers and replicative activity of HBV in CHB patients with or without HBeAg.

METHODS

This study recruited 111 untreated immune-active CHB (60 HBeAg-positive and 51 HBeAg-negative) patients and quantified intrahepatic covalently closed circular DNA (cccDNA), pre-genomic RNA (pgRNA), total HBV DNA (tDNA), and replicative intermediates as well as serum HBV markers (HBV DNA, hepatitis B surface antigen, hepatitis B core-related antigen). Correlations between HBV markers and clinico-virological factors influencing expression levels of HBV markers were analysed.

RESULTS

Levels of all serum markers and intrahepatic cccDNA/tDNA as well as cccDNA transcriptional activity and virion productivity were significantly reduced in HBeAg-negative patients compared to those in HBeAg-positive patients. Additionally, correlations between intrahepatic cccDNA/pgRNA and serum markers were impaired in HBeAg-negative individuals. Aminotransferase levels were positively correlated with cccDNA transcriptional activity in HBeAg-positive patients, but not in HBeAg-negative patients. Notably, among HBeAg-positive patients, there was a progressive decline in pgRNA level, transcriptional activity, and serum HBV markers as liver fibrosis advanced, which was not observed in HBeAg-negative patients.

CONCLUSIONS

HBeAg loss is correlated with diminished intrahepatic HBV reservoirs and cccDNA transcription, leading to decreased serum HBV marker levels. Circulating HBV markers are not reliable indicators of intrahepatic HBV replicative activity for HBeAg-negative patients. Our findings reveal distinct disease phenotypes between immune-active CHB with and without HBeAg, highlighting the need to establish optimal surrogate biomarkers that can accurately mirror intrahepatic viral activity to aid in decision-making for antiviral therapy for immune-active CHB.

Risk assessment of hepatitis B virus-related hepatocellular carcinoma development using vibration-controlled transient elastography: Systematic review and meta-analysis

BACKGROUNDS/AIMS

Liver stiffness measurement (LSM) using vibration-controlled transient elastography (VCTE) can assess fibrotic burden in chronic liver diseases. The systematic review and meta-analysis was conducted to determine whether LSM using VCTE can predict the risk of development of hepatocellular carcinoma (HCC) in chronic hepatitis B (CHB) patients.

METHODS

A systematic literature search of the Ovid-Medline, EMBASE, Cochrane, and KoreaMed databases (from January 2010 to June 2023) was conducted. Of the 1,345 individual studies identified, 10 studies that used VCTE were finally registered. Hazard ratios (HRs) and the 95% confidence intervals (CIs) were considered summary estimates of treatment effect sizes of ≥11 kilopascal (kPa) standard for HCC development. Meta-analysis was performed using the restricted Maximum Likelihood random effects model.

RESULTS

Among the ten studies, data for risk ratios for HCC development could be obtained from nine studies. When analyzed for the nine studies, the HR for HCC development was high at 3.33 (95% CI, 2.45-4.54) in CHB patients with a baseline LSM of ≥11 kPa compared to patients who did not. In ten studies included, LSM of ≥11 kPa showed the sensitivity and specificity for predicting HCC development were 61% (95% CI, 50-71%) and 78% (95% CI, 66-86%), respectively, and the diagnostic accuracy was 0.74 (95% CI, 0.70-0.77).

CONCLUSION

The risk of HCC development was elevated in CHB patients with VCTE-determined LSM of ≥11 kPa. This finding suggests that VCTE-determined LSM values may aid the risk prediction of HCC development in CHB patients.

Risk of dyslipidaemia in people living with HIV who are taking tenofovir alafenamide: a systematic review and meta-analysis

INTRODUCTION

Among many antiretroviral drugs, tenofovir alafenamide is used extensively in combination regimens of tenofovir/emtricitabine or tenofovir/emtricitabine/bictegravir. However, concerns have arisen about the potential of tenofovir alafenamide to exacerbate hyperlipidaemia. This meta-analysis evaluates the relationship between tenofovir alafenamide use and lipid-profile alterations in people living with HIV.

METHODS

We searched PubMed, Ovid MEDLINE, EMBASE and the Cochrane Library to identify studies on changes in cholesterol levels (e.g. total cholesterol, low-density and high-density lipoprotein cholesterol, and triglycerides) in people living with HIV who received treatment with a regimen containing tenofovir alafenamide (data collected 31 March 2023, review completed 30 July 2023). Potential risk factors for worsening lipid profile during treatment with tenofovir alafenamide were also evaluated.

RESULTS

Sixty-five studies involving 39,713 people living with HIV were selected. Significant increases in total cholesterol, low-density and high-density lipoprotein cholesterol, and triglycerides were observed after treatment with tenofovir alafenamide. Specifically, low-density lipoprotein cholesterol (+12.31 mg/dl) and total cholesterol (+18.86 mg/dl) increased markedly from the third month of tenofovir alafenamide use, with significant elevations observed across all time points up to 36 months. Comparatively, tenofovir alafenamide regimens resulted in higher lipid levels than tenofovir disoproxil fumarate regimens at 12 months of use. Notably, discontinuation of the tenofovir alafenamide regimen led to significant decreases in low-density lipoprotein cholesterol (-9.31 mg/dl) and total cholesterol (-8.91 mg/dl). Additionally, tenofovir alafenamide use was associated with increased bodyweight (+1.38 kg; 95% confidence interval: 0.92-1.84), which became more pronounced over time. Meta-regression analysis identified young age, male sex and low body mass index as risk factors for worsening cholesterol levels in individuals treated with tenofovir alafenamide.

CONCLUSIONS

Tenofovir alafenamide use in people living with HIV is associated with significant alterations in lipid profile.

Lack of association between early on-treatment HBeAg seroclearance and development of hepatocellular carcinoma or decompensated cirrhosis

BACKGROUND & AIMS

The association between hepatitis B envelope antigen (HBeAg) seroclearance during long-term nucleos(t)ide analogue (NA) treatment and the risk of hepatocellular carcinoma (HCC) in patients with chronic hepatitis B (CHB) remains unclear. Here, we aimed to investigate the association of HBeAg seroclearance during potent NA treatment with the development of HCC and decompensated cirrhosis.

METHODS

Using a multicenter historical cohort including 2,392 non-cirrhotic adult patients with HBeAg-positive CHB who initiated NA treatment with tenofovir or entecavir, the risk of HCC and decompensated cirrhosis was compared between patients who achieved HBeAg seroclearance within 36 months of NA treatment (the HBeAg-loss group) and those who did not (the HBeAg-maintained group), using inverse probability of treatment weighting.

RESULTS

Over a median of 6.6 years of NA treatment, 1,077 patients achieved HBeAg seroclearance (HBeAg loss rate = 6.0 per 100 person-years), 64 patients developed HCC (HCC incidence rate = 0.39 per 100 person-years), and 46 patients developed decompensated cirrhosis (decompensation incidence rate = 0.28 per 100 person-years). The HBeAg-loss and HBeAg-maintained groups had a similar risk of developing HCC (hazard ratio 0.89; 95% CI 0.47-1.68; p = 0.72) and decompensated cirrhosis (hazard ratio 0.98; 95% CI 0.48-1.81; p = 0.91). Compared with delayed HBeAg seroclearance beyond 10 years of NA treatment, the risk of HCC was comparable in those who achieved earlier HBeAg seroclearance at any time point within 10 years, regardless of baseline age and fibrotic burden.

CONCLUSIONS

Early HBeAg seroclearance during NA treatment was not associated with a reduced risk of development of HCC or decompensated cirrhosis in non-cirrhotic HBeAg-positive patients with CHB.

IMPACT AND IMPLICATIONS

The association between hepatitis B envelope antigen (HBeAg) seroclearance during long-term nucleos(t)ide analogue treatment and the risk of hepatocellular carcinoma in patients with chronic hepatitis B remains unclear. Our findings indicate that early on-treatment HBeAg seroclearance within 3 years was not associated with the development of hepatocellular carcinoma or decompensated cirrhosis. Achieving HBeAg seroclearance may not be an appropriate surrogate endpoint for preventing the development of liver-related outcomes in non-cirrhotic patients with HBeAg-positive chronic hepatitis B treated with nucleos(t)ide analogues.

Extrahepatic malignancies and antiviral drugs for chronic hepatitis B: A nationwide cohort study

BACKGROUND/AIMS

Chronic hepatitis B (CHB) is related to an increased risk of extrahepatic malignancy (EHM), and antiviral treatment is associated with an incidence of EHM comparable to controls. We compared the risks of EHM and intrahepatic malignancy (IHM) between entecavir (ETV) and tenofovir disoproxil fumarate (TDF) treatment.

METHODS

Using data from the National Health Insurance Service of Korea, this nationwide cohort study included treatment-naïve CHB patients who initiated ETV (n=24,287) or TDF (n=29,199) therapy between 2012 and 2014. The primary outcome was the development of any primary EHM. Secondary outcomes included overall IHM development. E-value was calculated to assess the robustness of results to unmeasured confounders.

RESULTS

The median follow-up duration was 5.9 years, and all baseline characteristics were well balanced after propensity score matching. EHM incidence rate differed significantly between within versus beyond 3 years in both groups (P<0.01, Davies test). During the first 3 years, EHM risk was comparable in the propensity score-matched cohort (5.88 versus 5.84/1,000 person-years; subdistribution hazard ratio [SHR]=1.01, 95% confidence interval [CI]=0.88-1.17, P=0.84). After year 3, however, TDF was associated with a significantly lower EHM incidence compared to ETV (4.92 versus 6.91/1,000 person-years; SHR=0.70, 95% CI=0.60-0.81, P<0.01; E-value for SHR=2.21). Regarding IHM, the superiority of TDF over ETV was maintained both within (17.58 versus 20.19/1,000 person-years; SHR=0.88, 95% CI=0.81-0.95, P<0.01) and after year 3 (11.45 versus 16.20/1,000 person-years; SHR=0.68, 95% CI=0.62-0.75, P<0.01; E-value for SHR=2.30).

CONCLUSION

TDF was associated with approximately 30% lower risks of both EHM and IHM than ETV in CHB patients after 3 years of antiviral therapy.

Efficacy comparison of high-genetic barrier nucleos(t)ide analogues in treatment-naïve chronic hepatitis B patients: a network meta-analysis

BACKGROUND/AIMS

Four high-genetic barrier nucleos(t)ide analogues (NAs) for chronic hepatitis B (CHB), namely entecavir (ETV), tenofovir disoproxil fumarate (TDF), tenofovir alafenamide (TAF), and besifovir dipivoxil maleate (BSV), have been established. The aim of this study is to investigate the efficacy of four high-genetic barrier NAs using a network meta-analysis of randomized trials and propensity score-matched cohorts.

METHODS

Systematic search was performed using PubMed, Cochrane library, and EMBASE and included randomized controlled trials and cohort studies that used propensity score matching. Studies on treatment-naïve CHB patients treated with ETV, TDF, TAF, or BSV were included. Outcomes included alanine aminotransferase normalization and hepatitis B e antigen seroclearance at week 48 and undetectable hepatitis B virus DNA at weeks 48 and 96. Network meta-analysis was performed to synthesize the results.

RESULTS

In total, 15,000 patients from 16 studies were included. In terms of 48- and 96-week virologic response (VR), TDF outperformed ETV with statistical significance (48 weeks: odds ratio [OR], 1.38; p < 0.001; 96 weeks: OR, 1.57; p = 0.004). ETV was ranked first for 48-week biochemical response (BR) and outperformed TDF (OR, 0.76; p = 0.028). In the sensitivity analyses, 48-week VR from randomized-controlled trials were compiled, and the same trend toward the superiority of TDF over ETV was found (OR, 1.51; p = 0.030).

CONCLUSION

Four high-genetic barrier NAs were compared, and TDF was more likely to achieve a VR after 48 weeks, while ETV provided a superior BR after 48 weeks.

Clinical profile and parameters of patients monoinfected with HBV and infected with HDV in Western Amazon

Background

Hepatitis Delta represents a greater risk in the progression of advanced liver disease and HCC compared with HBV. The exact mechanism that determines the spontaneous clearance of delta virus or its progression to cirrhosis remains unknown. Therefore, this study aimed to analyze the clinical profile of HBV and HBV/HDV individuals in the Western Amazon.

Methods

The study was carried out at the Specialized Outpatient Clinic for Viral Hepatitis belonging to the Centro de Pesquisa em Medicina Tropical de Rondônia/CEPEM. 100 individuals were included, stratified into two groups: 50 with hepatitis B virus and 50 with hepatitis Delta virus.

Results

The overall mean age was 48 years. For the HBV and HDV groups, 66 % (33/50) and 54 % (27/50) were men and 56 % (28/50) and 58 % (29/50) were on antiviral treatment, respectively. Patients with detectable HDV-RNA demonstrated high levels of ALT and AST compared to individuals with undetectable HDV-RNA. Comparative analysis between HBV carriers and infected with HDV shows significant differences in terms of age, HBV-DNA levels, albumin, hepatomegaly and splenomegaly.

Conclusion

Several markers were important for differentiating HBV and HDV infections. HDV-RNA detectable showed significant changes in biomarkers compared to undetectable patients, suggesting a possible worse prognostic effect in this group.

Macrophage-2-Binding Protein Glycosylation Isomer (M2BPGi) and AGAP Score as Markers of Noninvasive Test for Liver Fibrosis versus FibroScan in Chronic Hepatitis B Patients: A Retrospective Observational Study

Background

Liver biopsy as the gold standard for assessing the degree and diagnosis of fibrosis still has significant drawbacks, which make the emergence of a much less invasive diagnostic marker possible. M2BPGi levels and the AGAP score, the two newest serological markers, are known to have good sensitivity for detecting liver fibrosis. This study is aimed at determining the validity of examining M2BPGi levels and AGAP scores on the Fibroscan examination as markers of noninvasive test for liver fibrosis in chronic hepatitis B patients.

Methods

This is an observational, descriptive study with a retrospective design. This study used secondary data taken from medical records and blood specimen research materials of outpatients at the Hepatology Gastroenterology Polyclinic at a tertiary general hospital in West Java, Indonesia, with a diagnosis of chronic hepatitis B.

Results

There were 109 research subjects included. There were 73 (66.9%) subjects with no- or low-grade fibrosis and 36 (33.1%) with advanced fibrosis. The sensitivity and specificity of the M2BPGi were 88.9% and 61.6% (PPV 55.3%; NPV 91.8%; AUC 0.753), while the AGAP score was 47.2% and 100% (PPV 100%; NPV 79.3%; AUC 0.736). The combined M2BPGi level and the AGAP score showed a sensitivity of 80.9% and a specificity of 100% (PPV 100%; NPV 91.8%; AUC 0.905).

Conclusion

The AGAP score and M2BPGi levels together are a better way to measure the degree of liver fibrosis in people with chronic hepatitis B than either M2BPGi or the AGAP score alone.

Biogenesis of serum HBV RNA and clinical phenomena of serum HBV RNA in chronic hepatitis B patients before and after receiving nucleos(t)ide analogues therapy

There are estimated 300 million people afflicted with chronic hepatitis B (CHB) worldwide. The risk of liver cirrhosis and hepatocellular carcinoma (HCC) increases considerably with chronic hepatitis B infection. While current therapeutics are effective in controlling hepatitis B virus (HBV) infection and disease progression, a cure for HBV infection remains unattainable due to an intranuclear replicative intermediate known as covalently closed circular DNA (cccDNA). It has recently been shown that serum HBV RNA is a non-invasive biomarker that reflects cccDNA transcriptional activity. This review provides a comprehensive overview and the latest updates on the molecular characteristics and clinical significance of serum HBV RNA, such as species of serum HBV RNA, forms of serum HBV RNA carriers and predictive value for relapses in CHB patients after nucleos(t)ide analogues (NAs) discontinuation and development of liver fibrosis and HCC. Furthermore, we summarize standardized assays for testing serum HBV RNA, the dynamic changes of serum HBV RNA levels in treatment-naïve CHB patients and those under NAs therapy, as well as the host and viral influencing factors of serum HBV RNA levels. Finally, we discuss the future perspectives in studies of serum HBV RNA.

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

OBJECTIVE

The association between baseline pretreatment serum HBV DNA levels and on-treatment hepatocellular carcinoma (HCC) risk remains controversial in patients with chronic hepatitis B (CHB). We aimed to investigate the association between baseline HBV viral load and on-treatment HCC risk in CHB patients without cirrhosis.

DESIGN

Using a multicentre historical cohort study including 4693 hepatitis B e antigen (HBeAg)-negative and HBeAg-positive, adult CHB patients without cirrhosis who initiated antiviral treatment, HCC risk was estimated by baseline HBV viral load as a categorical variable.

RESULTS

During a median of 7.6 years of antiviral treatment, 193 patients developed HCC (0.53 per 100 person- years). Baseline HBV DNA level was independently associated with on-treatment HCC risk in a non-linear, parabolic pattern. Patients with moderate baseline viral loads (5.00-7.99 log10 IU/mL) exhibited the highest HCC risk (HR, 2.60; p<0.001), followed by those with low viral loads (3.30-4.99 log10 IU/mL; HR, 1.66; p=0.11). Patients with high viral loads (≥8.00 log10 IU/mL) presented the lowest HCC risk. Particularly, patients with baseline HBV DNA levels 6.00-6.99 log10 IU/mL had the highest on-treatment HCC risk (HR, 3.36; p<0.001) compared with those with baseline HBV DNA levels≥8.00 log10 IU/mL. These findings were more prominent among HBeAg-positive patients, younger patients, or those with less advanced hepatic fibrosis.

CONCLUSION

Patients with moderate baseline viral load, particularly around 6 log10 IU/mL, demonstrated the highest on-treatment HCC risk, despite long-term antiviral treatment. Early initiation of antiviral treatment, tailored to viral load, should be considered to minimise HCC risk in adult CHB patients without cirrhosis.

Gray zone of hepatitis B virus infection

ABSTRACT

A substantial proportion of patients with chronic hepatitis B (CHB) do not fall into any of the defined phases and are considered to be in the "gray zone" or "indeterminate phase." Most of the current clinical practice guidelines have no recommendations for antiviral treatment for them. However, the gray zone CHB patients with significant hepatitis B virus levels (>2000 IU/mL) and persistently normal alanine aminotransferase (ALT) levels have a significantly high risk of hepatic inflammation, fibrosis, and hepatocellular carcinoma. The molecular, clinical, and economic data that we have reviewed collectively in this article provide support for simplification of treatment initiation strategies that incorporate broader treatment of adult patients with CHB in the gray zone (hepatitis B virus [HBV] DNA ≥2000 IU/mL), regardless of ALT levels.

Long-Term HBsAg Titer Kinetics with Entecavir/Tenofovir: Implications for Predicting Functional Cure and Low Levels

The long-term kinetics of quantitative HBsAg levels in HBV-infected patients treated with entecavir or tenofovir, as well as the role of quantitative HBsAg in predicting functional cure (HBsAg loss) and low HBsAg levels (<2 log IU/mL) remain unclear. Of some 1661 consecutively enrolled patients newly treated with entecavir or tenofovir, we analyzed 852 patients who underwent serial HBsAg level checks every 6-12 months. The primary outcomes included long-term kinetics in HBsAg levels and the rate of functional cure and achieving low HBsAg levels. Over a mean 6.3-year follow-up, the functional cure rate was 2.28% (n = 19), and 12.9% (n = 108) achieved low HBsAg levels. A significant HBsAg level reduction was seen in the first treatment year (p < 0.05), with another stepwise decrease between year 6-7. These trends were pronounced in patients with chronic hepatitis and HBeAg-positivity compared to those with cirrhosis and HBeAg-negativity, respectively. Baseline HBsAg of ≤3 log IU/mL and the first-year HBsAg reduction were key predictors for both functional cure and low HBsAg levels (p < 0.05). In conclusion, our findings elucidate the stepwise reduction in quantitative HBsAg dynamics during high-potency NA therapy (entecavir or tenofovir) along with variations based on different conditions. We also underscore the significance of quantitative HBsAg titer in predicting functional cure and low-HBsAg levels.

Longitudinal changes in renal function in patients with chronic hepatitis B on antiviral treatment

BACKGROUND

Patients with chronic hepatitis B (CHB) on nucleos(t)ide analogues (NUCs) often experience renal function decline. Conflicting results regarding the impact of NUC use and renal function have recently been reported.

AIM

To examine longitudinal changes in renal function according to the NUC treatment type compared with untreated patients METHODS: From 2014 to 2022, we retrospectively analysed 10,642 patients with CHB. The primary outcome was chronic kidney disease (CKD) progression, which was defined as a minimum one-stage elevation. We applied propensity score (PS) matching for outcome comparisons.

RESULTS

In the PS-matched cohort of 1996 pairs, the NUC-treated group (7.6/100 person-years [PYs]) had a significantly higher CKD progression risk than the untreated group (4.4/100 PYs), with a hazard ratio (HR) of 1.70 (p < 0.001). The tenofovir disoproxil fumarate (TDF)-treated group (7.9/100 PYs) showed a 1.76-fold increased CKD progression risk compared with the untreated group (4.5/100 PYs) in the PS-matched cohort (p < 0.001). Both the entecavir- and tenofovir alafenamide (TAF)-treated groups showed CKD progression risks comparable to those of the untreated group in the PS-matched cohorts of 755 and 426 pairs, respectively (p = 0.132 and p = 0.120, respectively). No significant CKD progression risk was found between the entecavir- (6.0/100 PYs) and TAF-treated (5.2/100 PYs) groups in the PS-matched cohort of 510 pairs (p = 0.118).

CONCLUSIONS

NUC-treated patients, especially those on TDF, faced a higher CKD progression risk than untreated patients. Entecavir- and TAF-treated patients had comparable CKD progression risks to untreated patients. No difference was observed between entecavir and TAF in the risk of CKD progression.

PAGE-B incorporating moderate HBV DNA levels predicts risk of HCC among patients entering into HBeAg-positive chronic hepatitis B

BACKGROUND & AIMS

Recent studies reported that moderate HBV DNA levels are significantly associated with hepatocellular carcinoma (HCC) risk in hepatitis B e antigen (HBeAg)-positive, non-cirrhotic patients with chronic hepatitis B (CHB). We aimed to develop and validate a new risk score to predict HCC development using baseline moderate HBV DNA levels in patients entering into HBeAg-positive CHB from chronic infection.

METHODS

This multicenter cohort study recruited 3,585 HBeAg-positive, non-cirrhotic patients who started antiviral treatment with entecavir or tenofovir disoproxil fumarate at phase change into CHB from chronic infection in 23 tertiary university-affiliated hospitals of South Korea (2012-2020). A new HCC risk score (PAGED-B) was developed (training cohort, n = 2,367) based on multivariable Cox models. Internal validation using bootstrap sampling and external validation (validation cohort, n = 1,218) were performed.

RESULTS

Sixty (1.7%) patients developed HCC (median follow-up, 5.4 years). In the training cohort, age, gender, platelets, diabetes and moderate HBV DNA levels (5.00-7.99 log10 IU/ml) were independently associated with HCC development; the PAGED-B score (based on these five predictors) showed a time-dependent AUROC of 0.81 for the prediction of HCC development at 5 years. In the validation cohort, the AUROC of PAGED-B was 0.85, significantly higher than for other risk scores (PAGE-B, mPAGE-B, CAMD, and REAL-B). When stratified by the PAGED-B score, the HCC risk was significantly higher in high-risk patients than in low-risk patients (sub-distribution hazard ratio = 8.43 in the training and 11.59 in the validation cohorts, all p <0.001).

CONCLUSIONS

The newly established PAGED-B score may enable risk stratification for HCC at the time of transition into HBeAg-positive CHB.

IMPACT AND IMPLICATIONS

In this study, we developed and validated a new risk score to predict hepatocellular carcinoma (HCC) development in patients entering into hepatitis B e antigen (HBeAg)-positive chronic hepatitis B (CHB) from chronic infection. The newly established PAGED-B score, which included baseline moderate HBV DNA levels (5-8 log10 IU/ml), improved on the predictive performance of prior risk scores. Based on a patient's age, gender, diabetic status, platelet count, and moderate DNA levels (5-8 log10 IU/ml) at the phase change into CHB from chronic infection, the PAGED-B score represents a reliable and easily available risk score to predict HCC development during the first 5 years of antiviral treatment in HBeAg-positive patients entering into CHB. With a scoring range from 0 to 12 points, the PAGED-B score significantly differentiated the 5-year HCC risk: low <7 points and high ≥7 points.

Cardiovascular risk in chronic hepatitis B patients treated with tenofovir disoproxil fumarate or tenofovir alafenamide

BACKGROUND/AIMS

Tenofovir disoproxil fumarate (TDF) is known to have a lipid-lowering effect. This is in contrast to tenofovir alafenamide (TAF), which has a lipid-neutral effect. Therefore, concerns have been raised as to whether these differences affect long-term cardiovascular risk. Here, we aimed to evaluate the long-term risk of cardiovascular events in chronic hepatitis B (CHB) patients treated with TAF or TDF.

METHODS

We retrospectively analyzed 4,124 treatment-naïve CHB patients treated with TDF (n=3,186) or TAF (n=938) between 2012 and 2022. The primary outcome was a composite endpoint of major adverse cardiovascular events (MACE), including myocardial infarction, ischemic stroke, and hospitalization for unstable angina or heart failure. Serial changes in lipid profiles between two treatments were also explored.

RESULTS

The median age of the patients was 50.6 years, and 60.6% of the patients were male. At baseline, 486 (11.8%) and 637 (15.4%) of the patients had dyslipidemia and fatty liver, respectively. A total of 42 MACE occurred, with an annual incidence of 0.2%/100 person-years (PYs). At 1, 3, and 5 years, the cumulative risk of MACE was 0.4%, 0.8%, and 1.2% in patients treated with TDF, and 0.2%, 0.7%, and 0.7% in patients treated with TAF, respectively (p=0.538). No significant differences in the risk of MACE were observed between TDF and TAF. A multivariable analysis found that current smoker and a history of cardiovascular events were risk factors associated with an increased risk of MACE.

CONCLUSION

Patients treated with TAF had comparable risks of cardiovascular outcomes, defined as MACE, as patients treated with TDF.

The Clinical Courses and Prognosis of Cirrhotic Patients after First Acute Decompensation: Prospective Cohort Study

BACKGROUND

The European Foundation for the Study of Chronic Liver Failure (EF-CLIF) consortium suggested that the clinical courses after acute decompensation (AD) stratify the long-term prognosis: stable decompensated cirrhosis (SDC), unstable decompensated cirrhosis (UDC), pre acute-on-chronic liver failure (pre ACLF), and ACLF. However, previous studies included patients with a history of previous AD and had limitations associated with identifying the clinical factors related to prognosis after the first AD.

METHOD

The prospective Korean Acute-on-Chronic Liver Failure (KACLiF) cohort included cirrhotic patients who were hospitalised with first AD between July 2015 and August 2018. We analysed the factors associated with readmission after the first AD and compared the characteristics and prognosis among each subgroup to evaluate the risk factors for the occurrence of pre ACLF after AD.

RESULT

A total of 746 cirrhotic patients who were hospitalised with first AD were enrolled. The subgroups consisted of SDC (n = 565), UDC (n = 29), pre ACLF (n = 28), and ACLF (n = 124). Of note, pre ACLF showed a poorer prognosis than ACLF. The risk factors associated with readmission within 3 months of first AD were non-variceal gastrointestinal (GI) bleeding, hepatic encephalopathy (HE), and high MELD score. Viral aetiology was associated with the occurrence of pre ACLF compared with alcohol aetiology regardless of baseline liver function status.

CONCLUSION

Cirrhotic patients with first AD who present as non-variceal GI bleeding and HE can easily relapse. Interestingly, the occurrence of AD with organ failure within 3 months of first AD (pre ACLF) has worse prognosis compared with the occurrence of organ failure at first AD (ACLF). In particular, cirrhotic patients with viral hepatitis with/without alcohol consumption showed poor prognosis compared to other aetiologies. Therefore, patients with ACLF after AD within 3 months should be treated more carefully and definitive treatment through LT should be considered.

Hepatocellular carcinoma presenting as organized liver abscess: A case report

BACKGROUND

Hepatocellular carcinoma (HCC) is difficult to treat and has a high mortality rate, emphasizing the importance of early diagnosis and treatment. If characteristic radiologic findings and underlying liver disease are present, a diagnosis can be made without a biopsy. However, when HCC is accompanied by a liver abscess, diagnosis might be delayed by atypical radiologic findings. This case report aims to assist in the diagnosis of HCC, which can manifest in various forms.

CASE SUMMARY

A 75-year-old male presented to the Emergency Department with worsening fever and mental changes. He was diagnosed with liver cirrhosis six months earlier. Abdominal computed tomography (CT) raised our suspicion of an organized liver abscess. A follow-up CT scan after four weeks of antibiotic treatment showed a decrease in the liver lesion size. However, high fever recurred, and C-reactive protein increased to 14 mg/L. Aspiration of the liver lesion was performed, but no bacteria were identified. Blood culture revealed the presence of fungi. The patient received an additional four weeks of antibiotics and antifungal agents before being discharged. Approximately 10 mo later, a CT scan showed an increase in the lesion size, and biopsy was performed. The biopsy revealed an organized abscess with focal carcinomatous changes, for which surgery was performed. Postoperative histopathological examination revealed HCC, clear-cell variant. The nontumor liver tissue showed cirrhosis and an organized abscess.

CONCLUSION

Even if a liver abscess is suspected in a patient with cirrhosis, the possibility of HCC should be considered.

Adult-onset hypophosphatemic osteomalacia as a cause of widespread musculoskeletal pain: A retrospective case series of single center experience

BACKGROUND

Osteomalacia (OM) is frequently confused with various musculoskeletal or other rheumatic diseases, especially in patients with adult-onset widespread musculoskeletal pain because of its low prevalence and non-specific manifestations.

AIM

To facilitate the early diagnosis and etiology-specific treatment of adult-onset hypophosphatemic OM.

METHODS

A retrospective review of medical records was performed to screen adult patients who visited a physiatry locomotive medicine clinic (spine and musculoskeletal pain clinic) primarily presenting with widespread musculoskeletal pain at a single tertiary hospital between January 2011 and December 2019. We enrolled patients with hypophosphatemia, high serum bone-specific alkaline phosphatase levels, and at least one imaging finding suggestive of OM.

RESULTS

Eight patients with adult-onset hypophosphatemic OM were included. The back was the most common site of pain. Proximal dominant symmetric muscle weakness was observed in more than half of the patients. Bone scintigraphy was the most useful imaging modality for diagnosing OM because radiotracer uptake in OM showed characteristic patterns. Six patients were diagnosed with adefovir (ADV)-induced Fanconi syndrome, and the other two patients were diagnosed with tumor-induced OM and light-chain nephropathy, respectively. After phosphorus and vitamin D supplementation and treatment for the underlying etiologies, improvements in pain, muscle strength, and gait were observed in all patients.

CONCLUSION

Mechanical pain characteristics, hypophosphatemia, and distinctive bone scintigraphy patterns are the initial diagnostic indicators of adult-onset hypophosphatemic OM. ADV-induced Fanconi syndrome is the most common etiology of hypophosphatemic OM in hepatitis B virus-endemic countries.

Personalized Antiviral Drug Selection in Patients With Chronic Hepatitis B Using a Machine Learning Model: A Multinational Study

INTRODUCTION

Tenofovir disoproxil fumarate (TDF) is reportedly superior or at least comparable to entecavir (ETV) for the prevention of hepatocellular carcinoma (HCC) in patients with chronic hepatitis B; however, it has distinct long-term renal and bone toxicities. This study aimed to develop and validate a machine learning model (designated as Prediction of Liver cancer using Artificial intelligence-driven model for Network-antiviral Selection for hepatitis B [PLAN-S]) to predict an individualized risk of HCC during ETV or TDF therapy.

METHODS

This multinational study included 13,970 patients with chronic hepatitis B. The derivation (n = 6,790), Korean validation (n = 4,543), and Hong Kong-Taiwan validation cohorts (n = 2,637) were established. Patients were classified as the TDF-superior group when a PLAN-S-predicted HCC risk under ETV treatment is greater than under TDF treatment, and the others were defined as the TDF-nonsuperior group.

RESULTS

The PLAN-S model was derived using 8 variables and generated a c-index between 0.67 and 0.78 for each cohort. The TDF-superior group included a higher proportion of male patients and patients with cirrhosis than the TDF-nonsuperior group. In the derivation, Korean validation, and Hong Kong-Taiwan validation cohorts, 65.3%, 63.5%, and 76.4% of patients were classified as the TDF-superior group, respectively. In the TDF-superior group of each cohort, TDF was associated with a significantly lower risk of HCC than ETV (hazard ratio = 0.60-0.73, all P < 0.05). In the TDF-nonsuperior group, however, there was no significant difference between the 2 drugs (hazard ratio = 1.16-1.29, all P > 0.1).

DISCUSSION

Considering the individual HCC risk predicted by PLAN-S and the potential TDF-related toxicities, TDF and ETV treatment may be recommended for the TDF-superior and TDF-nonsuperior groups, respectively.