No Immediate Need for Nucleos(t)ide Analogs Treatment in Untreated Patients With Low-Level Viremia: Evidence From Hepatitis B Virus RNA Levels

Abstract

INTRODUCTION:

Uncertainty persists regarding viral replication activity in untreated low-level viremia (LLV) patients and the need for antiviral therapy. This study compared serum hepatitis B virus (HBV) RNA levels in untreated LLV patients, those developing LLV post-nucleos(t)ide analogs (NAs), and patients achieving maintained virological response (MVR).

METHODS:

A cross-sectional study enrolled untreated LLV, treated LLV, and MVR patients. Propensity score matching (PSM) minimized confounding variables.

RESULTS:

Among 364 patients (61 untreated LLV, 60 treated LLV, and 243 MVR), PSM analysis of 38 untreated-treated LLV pairs demonstrated significantly lower HBV RNA in untreated LLV (P < 0.001). Similarly, 1:2 PSM of untreated LLV vs MVR (58 vs 93 cases) revealed reduced HBV RNA in untreated LLV (P = 0.03).

DISCUSSION:

Untreated LLV patients exhibited lower HBV RNA levels than both treated LLV and MVR patients, reflecting reduced viral transcription and replication. This suggests that antiviral treatment may not be immediately necessary for this subpopulation.

INTRODUCTION

Current guidelines for chronic hepatitis B management emphasize expanding antiviral therapy indications (1–4), yet initiating treatment in untreated low-level viremia (LLV) patients remains controversial. Clinical evidence for antiviral treatment in this patient group needs further refinement, especially as existing cohort studies only focus on patients with compensated cirrhosis (5,6). Since clinical outcomes take long to observe, certain biomarkers of viral transcription and replication may offer valuable evidence.

Serum hepatitis B virus (HBV) RNA, reflecting transcription from covalently closed circular DNA (cccDNA), has emerged as a noninvasive biomarker for viral replication and treatment response (7–9). However, its role in untreated LLV patients remains unexplored.

This study aims to compare serum HBV RNA levels in untreated LLV patients with those developing LLV postnucleos(t)ide analogs (NAs) therapy and patients achieving maintained virological response (MVR), to unveil viral replication and provide evidence to guide decisions on whether antiviral therapy is warranted.

PATIENTS AND METHODS

Inclusion and exclusion criteria

This cross-sectional study enrolled patients from the Second Qilu Hospital of Shandong University between April and November 2023. Inclusion criteria were age 18 years or older, hepatitis B surface antigen (HBsAg) positivity for ≥6 months, and for those receiving antiviral therapy, good treatment adherence (defined as missing <10% of doses). Exclusion criteria included coinfection with hepatitis C virus or HIV, decompensated cirrhosis, or hepatocellular carcinoma (HCC).

Participant grouping

A total of 364 eligible patients were categorized into 3 groups:

Untreated LLV: treatment-naïve individuals with at least 1 HBV DNA level between 20 and 2,000 IU/mL.

Treated LLV: patients on first-line nucleos(t)ide analogs (entecavir, tenofovir disoproxil fumarate, or tenofovir alafenamide) for ≥48 weeks, with detectable HBV DNA (20–2,000 IU/mL) at enrollment.

MVR: HBeAg-negative patients who achieved sustained HBV DNA suppression (<20 IU/mL) after ≥48 weeks of nucleos(t)ide analogs therapy.

Statistical analyses

Continuous variables (mean ± SD or median [IQR]) were compared using Student t-test or Mann-Whitney U-tests; categorical variables (counts/percentages) through the χ²/Fisher exact test. Pairwise comparisons (untreated LLV vs treated LLV; untreated LLV vs MVR) were conducted to address the core clinical question of how untreated LLV differs from suboptimal and ideal treatment states; a 3-group Kruskal-Wallis test was also performed (see Supplementary Table S1, Supplementary Digital Content, http://links.lww.com/CTG/B451). Propensity score matching (PSM, tolerance = 0.2) balanced confounders (age, sex, cirrhosis, and HBV DNA). Analyses used R 4.3.1 and Free Statistics 1.8.

RESULTS

Clinical characteristics of the total population

The cohort included 61 untreated LLV, 60 treated LLV, and 243 MVR patients (Table 1). In addition, a 1:1:1 matched analysis between the 3 groups (47 patients per group) for age, sex, and cirrhosis was performed (see Supplementary Table S1, Supplementary Digital Content, http://links.lww.com/CTG/B451). Untreated LLV patients were predominantly HBeAg-negative (91.8%), whereas treated LLV patients were initially HBeAg-positive (93.3%). Median HBV RNA levels were 0.0 copies/mL (untreated LLV), 6.7 copies/mL (treated LLV), and 2.0 copies/mL (MVR).

Table 1.

Clinical characteristics of the enrolled patients

Variables	Total (n = 364)	Untreated LLV (n = 61)	Treated LLV (n = 60)	P valuea	MVR (n = 243)	P valueb	P valuec
Age, yr	47.6 ± 11.9	41.0 ± 9.7	45.8 ± 13.7	0.027	49.7 ± 11.2	<0.001	<0.001
Male, n (%)	252 (69.2)	34 (55.7)	40 (66.7)	0.217	178(73.3)	0.008	0.027
Antiviral agents, n (%)				NA		NA	NA
Entecavir	NA	NA	19 (31.7)		137 (56.4)
TFV	NA	NA	41 (68.3)		106 (43.6)
Cirrhosis, n (%)	114 (31.3)	2 (3.3)	11 (18.3)	0.008	101 (41.6)	<0.001	<0.001
Antiviral duration, mo	NA	NA	32.5 (20.0, 58.8)	NA	66.0 (39.0, 108.0)	NA	NA
ALT, U/L	23.0 (16.0, 32.0)	25.0 (17.0, 35.4)	27.0 (16.5, 37.0)	0.781	22.0 (16.0, 30.0)	0.085	0.043
AST, U/L	21.0 (18.0, 27.0)	21.0 (17.5, 28.0)	22.0 (18.0, 27.0)	0.633	21.0 (18.0, 26.0)	0.707	0.601
TBIL, µmol/L	14.7 (11.5, 19.9)	14.0 (11.2, 16.6)	13.8 (10.5, 18.3)	0.512	15.4 (11.6, 22.9)	0.013	0.025
Initial HBeAg positive, n (%)	61 (16.8)	5 (8.2)	56 (93.3)	<0.001	0 (0.0)	<0.001	<0.001
HBeAg, S/Co	0.6 (0.4, 0.9)	0.4 (0.4, 0.6)	349.0 (52.7, 810.7)	<0.001	0.6 (0.4, 0.7)	<0.001	<0.001
HBsAg, IU/mL	1,168.6 (186.3, 4,025.9)	1877.8 (645.2, 6,153.3)	6,871.0 (2,606.3, 17,782.9)	<0.001	598.8 (103.6, 1793.3)	<0.001	<0.001
lgHBV DNA, IU/mL	0.0 (0.0, 1.6)	2.5 (2.1, 2.9)	1.8 (1.4, 2.2)	<0.001	0.0 (0.0, 0.0)	<0.001	<0.001
Detectable HBV RNA, n (%)	195 (53.6)	17 (27.9)	59 (98.3)	<0.001	119 (49)	0.003	<0.001
lgHBV RNA, copies/mL	2.2 (0.0, 3.2)	0.0 (0.0, 2.2)	6.7 (5.9, 7.2)	<0.001	2.0 (2.0, 2.8)	<0.001	<0.001

Continuous variables were presented as either mean ± SD or median and interquartile range. All the antiviral duration ≥12 months.

ALT, alanine aminotransferase; AST, aspartate aminotransferase; HBeAg, hepatitis B e antigen; HBsAg, hepatitis B surface antigen; HBV, hepatitis B virus; LLV, low-level viremia; MVR, maintained virological response; NA, not applicable; TBIL, total bilirubin; TFV, tenofovir disoproxil fumarate or tenofovir alafenamide fumarate.

^aP values between the untreated LLV vs treated LLV groups.

^bP values between the untreated LLV vs MVR groups.

^cP values between the 3 groups.

HBV RNA levels after PSM between the untreated LLV group and the treated LLV or MVR groups

PSM analysis matched 38 pairs (76 cases) between untreated and treated LLV groups. After adjusting for age, sex, cirrhosis, and HBV DNA levels, the untreated LLV group exhibited significantly lower HBV RNA levels (median lgHBV RNA 0.0 vs 6.9 copies/mL, P < 0.001, Figure 1A). Notably, within the HBeAg-negative patient subgroup, treated LLV groups also exhibited significantly higher serum HBV RNA levels compared with their untreated counterparts (the median lgHBV RNA levels: 1.9 vs 1.0, P = 0.044).

Figure 1.

HBV RNA levels in chronic hepatitis B patients with untreated LLV, treated low-level viremia (treated LLV), and MVR. (A) Untreated LLV vs LLV groups and (B) MVR vs untreated LLV groups. HBV, hepatitis B virus; LLV, low-level viremia; MVR, maintained virological response.

For the untreated LLV and MVR comparison, a 1:2 PSM yielded 151 matched cases (58 cases in the untreated LLV group and 93 cases in the MVR group). After adjustment for age, sex, and cirrhosis, HBV RNA levels remained lower in the untreated LLV group (median lgHBV RNA 0.0 vs 2.0 copies/mL, P = 0.03, Figure 1B).

DISCUSSION

This study revealed significantly lower serum HBV RNA levels in untreated LLV patients compared with treated LLV and MVR groups, suggesting minimal viral replication activity. These findings imply that initiating NAs therapy immediately may not be warranted for untreated LLV patients.

Our analysis demonstrated markedly higher HBV RNA levels in treated LLV patients versus untreated LLV patients, indicating elevated viral replication. These findings underscore distinct clinical prognoses and therapeutic requirements between the 2 groups, necessitating differentiated management strategies.

Previous research associates persistent LLV during NAs therapy with elevated disease progression risk, emphasizing the importance of close monitoring and timely adjustments to treatment regimens in this population (10), supporting the potential role of HBV RNA quantification in risk stratification.

Conflicting evidence exists regarding HCC risk in untreated LLV patients. Yang et al. indicated the necessity for antiviral therapy in this population because of a higher incidence of HCC based on a long-term follow-up cohort study (6). Conversely, Lee et al. reported that episodic LLV does not significantly influence HCC risk in untreated patients with compensated cirrhosis (11). More recently, Huang et al also compared prognosis in compensated cirrhotic patients with LLV vs spontaneous undetectable HBV DNA in a multicenter study and concluded no increased risk of HCC (5). It is important to note that these studies primarily focus on patients with compensated cirrhosis, overlooking individuals with chronic hepatitis. Given these debates, further research is essential to solidify the evidence base regarding whether the benefits of antiviral therapy outweigh the adverse effects associated with long-term medication use in this population. However, obtaining the outcome of untreated patients with LLV who develop HCC or liver-related events requires a long follow-up period, which does not provide support for clinical decision-making in the short term.

Recently, HBV RNA, directly transcribed from cccDNA, has become an important viral activity indicator in hepatocytes (12,13). Serum HBV RNA is located in closer proximity to the source of viral replication compared with HBV DNA. This cross-sectional study enrolled 61 untreated and 303 compliant NAs-treated patients. Lower HBV RNA levels were found in untreated LLV patients. Using the PSM approach to balance other factors, we emphasized lower viral activity in untreated LLV patients. Long-term follow-up cohort studies are needed to validate these findings. Nevertheless, this conclusion is expected to be robust, given the fundamental mechanisms underlying HBV RNA production.

The expansion of chronic hepatitis B antiviral therapy indications poses challenges, including socioeconomic burdens and drug-related adverse events, necessitating individualized strategies guided by comprehensive evaluation. Future integration of HBV RNA levels into clinical guidelines may refine therapeutic precision.

The inherently subject of cross-sectional study introduces inherent biases, and although PSM mitigated confounders, it lacks a “solid endpoint” directly reflecting clinical outcomes. An additional limitation is the heterogeneous distribution of HBeAg status between untreated and treated LLV patients, which reflects the inherent heterogeneity of real-world cohorts. This confounding factor was mitigated through stratified subgroup analysis, the results of which consistently supported the primary conclusions, thereby reinforcing the robustness of the findings. Third, this study did not perform systematic HBV genotyping for all participants. However, given that genotype C predominates in northern China—the region of our institution—accounting for approximately 85% of cases (14), we infer a considerable genotypic homogeneity within our cohort. Nevertheless, our conclusions should be extrapolated with caution when applied to populations with distinct genotypic distributions. Furthermore, liver elastography data were not systematically collected in this study. The determination of cirrhosis was based on conventional imaging modalities (ultrasound, CT, or MRI). The lack of elastography-based fibrosis staging limits a more granular stratification of the noncirrhotic subgroup, particularly within the heterogeneous untreated LLV cohort, and represents an aspect for refinement in future studies.

In conclusion, this study revealed that patients in the untreated LLV group exhibited lower HBV RNA levels compared with both the treated LLV and MVR groups, reflecting diminished viral transcription and replication activity. This finding implies that antiviral treatment may not be immediately necessary for this subpopulation. Acknowledging the inherent limitations of cross-sectional study designs, definitive conclusions must ultimately be validated through prospective, longitudinal investigations using clinically hard endpoints.

CONFLICTS OF INTEREST

Guarantor of the article: Tao Li, MD.

Specific author contributions: Y.Z.: writing-original draft, validation, formal analysis, visualization, software. J.W.: resources, data curation, visualization, investigation. H.G.: resources, data curation, visualization. L.G.: investigation, formal analysis, funding acquisition. L.W.: visualization, investigation, formal analysis, funding acquisition. T.L.: methodology, writing-review & editing, funding acquisition, resources supervision, project administration.

Financial support: This study was funded by Shandong Province Natural Science Foundation (Nos. ZR2019PH052, ZR2023QH387, ZR2025MS1410).

Potential competing interests: None to report.

Ethics approval: The study has obtained approval from the Ethics Committee of The Second Hospital of Shandong University, and informed consent was acquired from all patients (Ethics approval number: KYLL-2023431).

Consent to participate: Informed consent was obtained from all individual participants included in the study.

Supplementary Material

ct9-17-e00970-s001.docx ^{(14.5KB, docx)}