Observational Study
Copyright ©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Sep 21, 2023; 29(35): 5166-5177
Published online Sep 21, 2023. doi: 10.3748/wjg.v29.i35.5166
Lowering the threshold of alanine aminotransferase for enhanced identification of significant hepatic injury in chronic hepatitis B patients
Hong-Sheng Yu, Hao Jiang, Ming-Kai Li, Bi-Lan Yang, Abdukyamu Smayi, Jian-Ning Chen, Bin Wu, Yi-Dong Yang
Hong-Sheng Yu, Hao Jiang, Ming-Kai Li, Bi-Lan Yang, Abdukyamu Smayi, Bin Wu, Yi-Dong Yang, Department of Gastroenterology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, Guangdong Province, China
Hong-Sheng Yu, Hao Jiang, Ming-Kai Li, Bi-Lan Yang, Abdukyamu Smayi, Bin Wu, Yi-Dong Yang, Department of Liver Disease, Guangdong Provincial Key Laboratory of Liver Disease Research, Guangzhou 510630, Guangdong Province, China
Jian-Ning Chen, Department of Pathology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, Guangdong Province, China
Author contributions: Yu HS and Jiang H have contributed equally to this work; Yu HS and Jiang H designed the study, performed the statistical analysis, and drafted the manuscript; Li MK, Yang BL, Smayi A and Chen JN collected the clinical data and then reviewed the data; Wu B and Yang YD revised the manuscript; Yang YD and Wu B were responsible for the study conception, design, data, analysis; All authors have read and approved the manuscript.
Supported by The Natural Science Foundation of Guangdong Province for Distinguished Young Scholar, No. 2022B1515020024; National Natural Science Foundation of China, No. 82070574; and The Natural Science Foundation Team Project of Guangdong Province, No. 2018B030312009.
Institutional review board statement: The study was reviewed and approved by the Third Affiliated Hospital of Sun Yat-Sen University. No. [2019]02-530-01.
Informed consent statement: All study participants provided informed written consent prior to study enrollment.
Conflict-of-interest statement: There are no conflicts of interest to report.
Data sharing statement: No additional data are available.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Yi-Dong Yang, PhD, Associate Professor, Department of Gastroenterology, The Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Tianhe District, Guangzhou 510630, Guangdong Province, China. yangyd6@mail.sysu.edu.cn
Received: July 2, 2023
Peer-review started: July 2, 2023
First decision: July 14, 2023
Revised: July 22, 2023
Accepted: August 31, 2023
Article in press: August 31, 2023
Published online: September 21, 2023
Processing time: 74 Days and 4.6 Hours
ARTICLE HIGHLIGHTS
Research background

In clinical practice, a considerable proportion of chronic hepatitis B (CHB) patients (27.8%-55%) fall into the “grey zone (GZ)” or “indeterminate phase”. Additionally, there is still debate regarding how best to treat these GZ patients and the advantages of antiviral therapy. Moreover, an issue that complicates the management of CHB is the disagreement regarding the appropriate treatment threshold for alanine aminotransferase (ALT) levels.

Research motivation

To explore the impact of varying the threshold of ALT levels in identifying significant hepatic injury (SHI) among GZ patients.

Research objectives

Our research evaluated the clinical and histological characteristics and additionally explored the impact of adjusting the threshold of ALT in identifying significant liver injury among GZ patients.

Research methods

This retrospective analysis involved a cohort of 1617 adult patients diagnosed with CHB who underwent liver biopsy. Significant hepatic injury was defined as the presence of notable liver inflammation (≥ G2) and/or significant fibrosis (≥ S2). Kruskal-Wallis tests and Pearson’s chi-squared tests were applied to compare variables that were significantly different between groups.

Research results

The study showed that 50.22% of the patients with HBV infection fell into the GZ category, and more than half of the patients (63.7%) in the GZ category exhibited SHI. The areas under the receiver operating characteristic curves of Aspartate aminotransferase-to-platelet ratio index, fibrosis score based on four factors, and gamma-glutamyl transpeptidase-to-platelet ratio in predicting SHI were 0.717, 0.713, and 0.727, respectively, in the HBeAg-positive GZ phases and 0.717, 0.645, and 0.692, respectively, in the HBeAg-negative GZ phases. Lowering the ALT treatment thresholds to the American Association for the Study of Liver Diseases 2018 treatment criteria can more accurately identify patients with significant liver damage in the GZ phases. When we lowered the ALT treatment threshold to the new criteria, the same outcome was revealed.

Research conclusions

This study showed that 50.22% of CHB patients were in the GZ, and over half of GZ patients (63.7%) had SHI. Lowering ALT thresholds can more accurately identify patients with significant liver damage at an earlier stage and reduce the need for some unnecessary liver biopsies. Furthermore, age may not be a limitation for initiating antiviral therapy in patients with CHB who have normal ALT levels.

Research perspectives

Further investigation is needed to determine the assessment and treatment strategy for CHB patients in the GZ phases.