Why Fewer Children Have Immune-Tolerant Hepatitis B Infection Than Previously

A recent study (KB Schwarz et al. JPGN 2019; 69: 588-94) highlights the chronic hepatitis B virus (HBV) phenotypes from a large pediatric North American cohort (n=371).

  • Immune-tolerant HBV was define by HBe-Ag-positivity along with normal ALT levels.
  • Inactive carrier were HBe-Ag-negative with low HBV DNA/normal ALT.
  • Chronic hepatitis B (HBeAg positive and HBeAg negative) had high HBV DNA and abnormal ALT values.
  • Indeterminant HBV had characteristics did not allow them to classified in these four categories.

Key findings:

  • If local laboratory normative values were used 36% of children would have been classified as immune-tolerant*.  However, this drops down to 12% if updated upper limits of normal (ULN) are used based on Figure 3.
  • Using updated ULN, 62% had immune active HBeAg+ disease, 12% with immune-tolerant HBV, 4% with immune-active HBeAg-negative disease, 6% with inactive carrier, and 16% indeterminant HBV.

*There are a few discrepancies between Figure 3 and the abstract data.  The abstract states that 82% would be considered to have chronic hepatitis B (this is 62% in figure 3). The abstract states that 35% were immune-tolerant based on local lab values.

The data presented were cross-sectional data at time of patient enrollment.

My take: this study shows that very few children in this cohort were immune tolerant based on more precise ULN values.  The authors note that the cohort who were immune tolerant were largely drawn from Asian children (most often infected perinatally).

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