Among patients with chronic hepatitis B, the cumulative incidence of severe alanine aminotransferase flares was low and correlated with decreased HBV DNA levels and loss of HBV e-antigen, according to recently published data.
“With the advent of sensitive HBV assays and new therapeutic agents, our understanding of the natural history, clinical outcomes, and management of ALT flares in chronic HBV infection has evolved,” Mayur Brahmania, MD, from Toronto General Hospital in Canada, and colleagues wrote. “Although ALT flares are infrequent, they do occur and can be associated with significant rises in ALT values … which probably warrant close monitoring in patients with advanced liver disease given the risk of decompensation.”
Brahmania and colleagues collected data from the Hepatitis B Research Network on 1,587 untreated patients with HBV to determine the incidence and outcomes of ALT flares. Of those enrolled, 102 experienced an ALT flare defined as more than 10 times the upper limit of normal.
Factors that correlated independently with an increased risk for an ALT flare included male sex (OR = 3.02; 95% CI, 1.59-5.74), higher HBV DNA values (OR = 1.41 per log 10; 95% CI, 1.24-1.6), alcohol misuse compared with moderate to no drinking (OR = 2.27; 95% CI, 1.16-4.42), and higher Fibrosis-4 Index values (OR = 1.85 per doubled value; 95% CI, 1.38-2.49).
In contrast, older age correlated with a lower risk for an ALT flare (OR = 0.63 per 10 years; 95% CI, 0.48-0.86).
Untreated patients with an ALT flare were significantly more likely to experience HBV DNA decreases of more than 1 log compared with those without a flare (59 vs. 23 per 100 person-years; P = .003). Similarly, HBeAg loss rates were significantly different between patients with and without an ALT flare (47 vs. 15 per 100 person-years; P = .002).
After the patients began treatment, the researchers observed no significant difference in HBV DNA decreases or HBeAg loss between those who had an ALT flare and those who did not.
Rates of HBV surface antigen loss were low in both groups and no significant difference in loss rates between the groups. Additionally, neither group had higher rates of hepatocellular carcinoma, liver transplantation or mortality.
“Our results should be interpreted in the context of a cohort with relatively mild disease … and that ALT flares were part of the natural history of chronic HBV infection as we excluded ALT flares during/after antiviral therapy, and in the setting of immunosuppression, chemotherapy, or superimposed infection,” the researchers wrote. “Thus, from this study no conclusions can be drawn as to when treatment is needed in patients with ALT flares.”
By Talitha Bennett