title: Alanine aminotransferase course, serum hepatitis B virus DNA, and liver stiffness measurement for therapeutic decisions in hepatitis B e antigen-negative chronic hepatitis B.
abstract: OBJECTIVE
  To evaluate the utility of the combination of alanine aminotransferase (ALT) course, hepatitis B virus (HBV) DNA level, and liver stiffness measurement (LSM) for determining significant liver disease in hepatitis B e antigen (HBeAg)-negative patients.
  
  
  METHODS
  Three hundred and ninety nine consecutive HBeAg-negative patients with HBV DNA >2000 IU/mL and documented serial measurements of ALT were enrolled to undergo LSM followed by liver biopsy.
  
  
  RESULTS
  Using ALT <40 IU/L as a normal value, 142 patients had persistently normal ALT (PNALT), whereas 257 had persistently or intermittently elevated ALT (PIEALT) in the prior year. Among patients with HBV DNA of 2000-19 999, 20 000-199 999, and ≥200 000 IU/mL, significant pathological lesions defined as the presence of moderate to severe necroinflammation and/or significant fibrosis by METAVIR scoring was present in 40%, 45%, and 71% of the PIEALT group, and 15%, 31%, and 36% of the PNALT group, respectively. In PNALT patients with HBV DNA <20 000 IU/mL, liver biopsy could be avoided in 88% when LSM <7 kPa is used as an indicator of non-significant liver histology but 12% of those who indeed had significant pathological lesions would be missed. In PIEALT patients with HBV DNA ≥20 000 IU/mL, the need for liver biopsy could be reduced by 53% with a false positive rate of 14% when LSM ≥7 kPa is used as a predictor of significant pathological lesions.
  
  
  CONCLUSIONS
  The combination of serial ALT, viral load, and LSM appears to be a promising non-invasive tool. A management algorithm for HBeAg-negative patients comprising these non-invasive measures is proposed with liver biopsy being pursued in selected cases.
authors.affiliation: Division of Gastroenterology, Department of Medicine.
authors.forename: Phunchai
authors.initials: P
authors.lastname: Charatcharoenwitthaya
authors.affiliation: Division of Gastroenterology, Department of Medicine.
authors.forename: Pochamana
authors.initials: P
authors.lastname: Phisalprapa
authors.affiliation: Division of Gastroenterology, Department of Medicine.
authors.forename: Nonthalee
authors.initials: N
authors.lastname: Pausawasdi
authors.affiliation: Department of Pathology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
authors.forename: Pimpattana
authors.initials: P
authors.lastname: Rungkaew
authors.affiliation: Department of Pathology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
authors.forename: Sorrayut
authors.initials: S
authors.lastname: Kajornvuthidej
authors.affiliation: Division of Gastroenterology, Department of Medicine.
authors.forename: Wimolrak
authors.initials: W
authors.lastname: Bandidniyamanon
authors.affiliation: Division of Gastroenterology, Department of Medicine.
authors.forename: Watcharasak
authors.initials: W
authors.lastname: Chotiyaputta
authors.affiliation: Division of Gastroenterology, Department of Medicine.
authors.forename: Siwaporn
authors.initials: S
authors.lastname: Chainuvati
authors.affiliation: Division of Gastroenterology, Department of Medicine.
authors.forename: Tawesak
authors.initials: T
authors.lastname: Tanwandee
keywords: alanine aminotransferase; elastography; hepatitis B; pathology; viral hepatitis