Letter: hepatic steatosis and fibrosis in chronic hepatitis B—the chicken‐and‐egg conundrum. Authors' reply

We thank Drs Huang and Kao for their interest in our recent article.1

They have raised several very important points about the development of fibrosis when both chronic hepatitis B (CHB) and steatosis are present. As they pointed out, if the presence of steatosis is associated with metabolic disorders, then the risk for fibrosis could also be influenced by these metabolic features and not just the viral activity of CHB.2-6 We performed this analysis and found that it was the metabolic features but not the viral factors which were closely associated with fibrosis (Table 1).

TABLE 1. Risk factors associated with fibrosis in CHB patients Risk factor Studies (N) Participants (n) OR/MD 95% CI P I2 (%) Metabolic factor Diabetes 4 354 2.75 1.50-5.05 0.001 76.0a Metabolic syndrome 3 346 4.31 1.21-15.32 0.02 89.9a BMI 6 1272 0.46 0.17-0.76 0.002 86.2a Waist circumference 4 621 0.67 0.30-1.04 0.0004 89.1a TC 4 587 −0.43 −0.88-0.03 0.07 90.4a TG 5 721 0.19 0.09-0.28 0.0002 7.2 Glucose 4 1263 0.23 −0.06-0.51 0.12 86.3a Viral factor HBeAg 7 2383 0.92 0.66-1.28 0.62 58.9a HBVDNA 3 469 −0.70 −1.73-0.32 0.18 96.4a ALT 3 533 0.01 −0.10-0.11 0.93 0.0 AST 4 563 0.26 0.08-0.45 0.005 45.3 OR, odds ratio; MD, mean differences; TC, total cholesterol; TG, triglyceride; ALT,alanine aminotransferase; AST,aspartate transaminase.

In addition, we would suggest that, as noted in our study, the presence of steatosis can inhibit viral replication which protected against the development of fibrosis.7 However, if the presence of steatosis was attributable to metabolic features, fibrosis could still occur. As noted by Drs Huang and Kao, these results will need further exploration; regardless, practitioners should be aware of this possibility especially as the HBV population is ageing and have more comorbidities.8 Therefore, treatment needs to be geared not only towards managing CHB but also towards controlling the metabolic features that are present.9

We thank Drs Huang and Kao for their careful critique of our article especially as the included studies in our meta-analysis were all published before the proposed new MAFLD criteria.10 We appreciate this opportunity to expand our work in conjunction with their insights.

The authors' declarations of personal and financial interests are unchanged from those in the original article.7

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