Liver Complications in Untreated Treatment-Ineligible versus Treated Treatment-Eligible Patients with Hepatitis B

Dig Dis. 2023;41(1):115-123. doi: 10.1159/000526933. Epub 2022 Sep 7.


Background: A substantial number of patients who do not meet treatment criteria for chronic hepatitis B (CHB) later develop adverse outcomes such as cirrhosis and hepatocellular carcinoma (HCC). Our aim was to determine whether current practice guidelines adequately identify CHB patients who will benefit from antiviral therapy.

Methods: We performed a retrospective cohort study comparing the incidence of adverse liver outcomes (cirrhosis and/or HCC) in untreated treatment-ineligible (at baseline and throughout follow-up) versus treated treatment-eligible patients according to standard American Association for the Study of Liver Diseases (AASLD) 2018 guidance (alanine aminotransferase [ALT] >70/50 U/L for men/women plus hepatitis B virus [HBV] DNA >20,000/2,000 IU/mL for HBeAg+/-) and with a sensitivity analyses using a lower threshold (ALT >40 U/L and HBV DNA >2,000 IU/mL).

Results: We reviewed records of 5,840 patients from 5 clinics in California and identified 2,987 treatment-naive non-HCC CHB patients. Of those, 271 patients remained untreated treatment-ineligible, 514 patients were treatment-eligible and initiated treatment, with 5-year cumulative adverse liver incidences of 12.5% versus 7.2%, p = 0.074. On multivariable analysis adjusting for age, sex, diabetes, albumin, platelet count, and HBV DNA, compared to treated treatment-eligible patients, untreated treatment-ineligible patients had a significantly higher risk of adverse liver outcomes (adjusted hazard ratio: 2.38, 95% confidence interval 1.03-5.48, p = 0.04) in main analysis by AASLD 2018 criteria but not in sensitivity analysis using the lower treatment threshold (p = 0.09).

Conclusion: Patients never meeting standard AASLD 2018 criteria for antiviral therapy and never treated had twice the risk of developing cirrhosis and/or HCC when compared to eligible and treated patients.

Keywords: Antiviral therapy; Hepatocellular carcinoma; Liver cirrhosis; Treatment guidelines.

Publication types

  • Review

MeSH terms

  • Antiviral Agents / therapeutic use
  • Carcinoma, Hepatocellular*
  • DNA, Viral / therapeutic use
  • Female
  • Hepatitis B e Antigens / therapeutic use
  • Hepatitis B virus
  • Hepatitis B, Chronic* / drug therapy
  • Humans
  • Liver Cirrhosis / complications
  • Liver Neoplasms*
  • Male
  • Retrospective Studies


  • DNA, Viral
  • Antiviral Agents
  • Hepatitis B e Antigens

Grants and funding

No funding was received by any of the authors for this study.