High risk of hepatocellular carcinoma and death in patients with immune-tolerant-phase chronic hepatitis B

Abstract

Untreated IT-phase patients with CHB had higher risks of HCC and death/transplantation than treated IA-phase patients. Unnecessary deaths could be prevented through earlier antiviral intervention in select IT-phase patients.

A simple AGED score for risk classification of primary liver cancer: development and validation with long-term prospective HBsAg-positive cohorts in Qidong, China

“…We read with great interest the recent publication by Kim et al 1 showing that patients with untreated immune tolerant (IT) chronic hepatitis B with normal alanine aminotransferase (ALT) levels had significantly higher risks of hepatocellular carcinoma (HCC) and death/transplantation than treated immune active (IA) patients who had elevated ALT levels. These results indicate that ALT is not a sensitive surrogate marker for liver cell damage, and the IT phase of HBV infection cannot be considered fully benign 2.…”

HBV infection and HCC: the ‘dangerous liaisons’

“…Purists will argue, with some reason, that classical IT patients have much higher levels of HBV viraemia. However, in our opinion, the most important information is that deconvolution of IT patients into groups with high (>10 8 ), intermediate (10 7 –10 7.9 ) and low (10 4 –10 6.9 ) levels of HBV-DNA shows that the risk of HCC development is higher among the category of patients with lower HBV-DNA levels (figure S3 of the paper1). Another interesting observation is that patients with minimally elevated ALT values (>ULN but<2 × ULN) are at higher risk of developing HCC as compared with subjects with genuinely normal serum ALT.…”

“…In this work, GA Kim and YS Lim directly measured the risk of hepatocellularcarcinoma (HCC) development in a cohort 413 patients with chronic hepatitis B (CHB) considered IT and followed for more than 10 years 1. The study shows that IT patients can develop HCC (~12% in 10 years), and provides evidence that the incidence of HCC in this group of IT patients is higher than that detected in treated ‘immune active’ patients (~6% in 10 years).…”

“…The first point to observe is that Kim  et al 1 defined the IT patients as those with HBV-DNA levels >20 000 IU/ML (~>10 5 copies × mL) and ALT values lower than 2 × ULN. Purists will argue, with some reason, that classical IT patients have much higher levels of HBV viraemia.…”

Prognosis of immune-tolerant phase chronic hepatitis B

“…We read with great surprise the article by Kim et al 1  reporting high risks of hepatocellular carcinoma (HCC) and death in patients with untreated chronic hepatitis B who were classified by them as patients in ‘immune-tolerant’ (IT) phase. This conclusion contradicts to the general belief that there is little or no disease progression during the IT phase of chronic HBV infection, as best demonstrated in a 5-year histological follow-up study 2.…”