No Significant Liver Disease or True Immune-tolerant HBeAg Positive Chronic Hepatitis B with Normal Serum ALT Levels

1.1. Background Hepatitis B e antigen (HBeAg)-positive Chronic hepatitis B (CHB) patients with normal alanine aminotransaminase (ALT) were usually considered to be in the immune-tolerant phase. However, it has been suggested that the current upper limit of normal for ALT should be lowered. 1.2. Aim To determine the prevalence and factors associated with no significant liver disease in those with normal ALT. 1.3. Method One-hundred and fifty-one HBeAg-positive CHB patients with normal ALT. Those with liver biopsy showing minimal or mild inflammation with ≤F1 fibrosis were defined as no significant liver disease, those who were truly immunetolerant. 1.4. Results One hundred and twenty-nine of the 151 patients (85.4%) had no significant liver disease. Those with no significant liver disease had a lower mean serum ALT (20 vs. 25 U/L, p=0.005) and a higher mean serum HBV DNA (7.85 vs. 7.09 log IU/ml, p=0.001) than those with significant liver disease. Those with no significant liver disease were more likely to have normal serum ALT as according to AASLD 2007 (90.7% vs. 59.1%, p=0.001) or AASLD 2018 (99.2% vs 77.3%, P<0.001) Practice Guidelines when compared with those with significant liver disease. On multivariate regression analysis, normal serum ALT as recommended by AASLD 2018 Practice Guideline was the only independent factor associated with no significant liver disease (p= 0.001, Odds Ratio 37.059, 95% Confidence Interval 4.082-336.452).