Abstract
Aim of the Study
CHB and MASLD are increasingly prevalent coexisting conditions that accelerate liver fibrosis progression and increase hepatocellular carcinoma risk. This study aimed to compare the antiviral efficacy and metabolic effects of PEG-IFNα-2b versus nucleos(t)ide analogues (NAs) in patients with the CHB-MASLD comorbidity.
Methods
This retrospective study enrolled 174 biopsy-confirmed CHB-MASLD patients treated at Xiamen Hospital of Traditional Chinese Medicine between July 2019 and July 2024. Patients received either PEG-IFNα-2b (n = 87) or NAs (n = 87) for ≥ 48 weeks. Primary outcomes included HBsAg seroclearance and quantitative reduction. Metabolic parameters, liver stiffness measurement (LSM), and controlled attenuation parameter (CAP) were assessed at baseline, 24 weeks, and 48 weeks. Multivariate linear regression was performed to evaluate treatment effects on metabolic changes, adjusting for baseline values, age, sex, HBeAg status, and BMI.
Results
At 48 weeks, PEG-IFNα-2b achieved significantly higher HBsAg seroclearance rates compared with NAs (P < 0.05) and a greater log reduction in HBsAg levels (P < 0.001). PEG-IFNα-2b also demonstrated superior metabolic benefits: significant reductions in total cholesterol (P < 0.001), LDL-cholesterol (P < 0.001), BMI (P < 0.001), and CAP values at 48 weeks (P < 0.05). However, PEG-IFNα-2b was associated with decreased HDL-cholesterol levels and a higher incidence of transient aminotransferase elevations (P < 0.001).
Conclusion
In CHB-MASLD patients, PEG-IFNα-2b provides better virological response and favorable metabolic modulation, supporting it may represent a promising treatment option.
Keywords: chronic hepatitis B, metabolic dysfunction-associated steatotic liver disease, pegylated interferon, nucleotide analogues, nucleoside analogues
Plain Language Summary
Chronic hepatitis B and metabolic dysfunction‑associated steatotic liver disease frequently coexist, and this comorbidity has been associated with an increased risk of cirrhosis and hepatocellular carcinoma. Current antiviral therapies, including nucleos(t)ide analogues (NAs) and pegylated interferon (PEG‑IFN), effectively suppress viral replication; however, they do not directly address the underlying metabolic disturbances inherent to MASLD.
Nevertheless, the impact of coexisting MASLD on the efficacy of these antiviral regimens remains controversial. Moreover, most previous investigations have focused on a single treatment modality or a single efficacy endpoint, leaving a gap in head‑to‑head comparisons of different strategies (NAs alone, PEG‑IFN alone, or their combination) within the same cohort. In addition, the potential effects of these antiviral agents on metabolic parameters—such as lipid profiles, body weight, and hepatic steatosis—have been underexplored in patients with CHB and concurrent MASLD. Given that metabolic improvement may hold clinical relevance, this gap warrants attention.
Therefore, we conducted this retrospective cohort study to compare the efficacy of different antiviral strategies in patients with CHB and coexisting MASLD, and to explore factors associated with treatment response, including both virologic and metabolic outcomes. Our goal is to provide real‑world evidence that may inform individualized clinical decision‑making.
Background
Chronic hepatitis B (CHB) is a chronic infectious liver disease caused by persistent infection with the hepatitis B virus (HBV), affecting approximately 296 million individuals globally.1 Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most prevalent chronic liver disease worldwide and has emerged as a significant public health threat. MASLD can progress to metabolic dysfunction-associated steatohepatitis, liver fibrosis, cirrhosis, and ultimately hepatocellular carcinoma. Furthermore, it is closely associated with extrahepatic metabolic disorders, such as type 2 diabetes and cardiovascular disease, significantly increasing the risk of all-cause mortality in affected patients2. In clinical practice, MASLD is often accompanied by multifaceted metabolic disturbances, with the incidence of concurrent dyslipidemia reaching 26.43%3. The co-existence of these conditions significantly elevates the incidence of major adverse cardiovascular events, such as coronary heart disease and stroke, while simultaneously accelerating the progression of liver fibrosis, thereby imposing a dual burden on both the liver and the systemic metabolic system4. The concurrent incidence of MASLD and CHB is increasing,5 and CHB complicated by MASLD further increases the risk of cirrhosis and hepatocellular carcinoma6. Pegylated interferon alpha-2b (PEG-IFNα-2b) and nucleos(t)ide analogues (NAs) are the two primary classes of antiviral agents currently used for CHB treatment7. PEG-IFNα-2b possesses both antiviral and immunomodulatory properties, facilitating the clinical cure goal of HBsAg seroclearance in a subset of patients8. NAs offer the advantages of rapid antiviral action, a stable safety profile, and potent suppression of HBV replication9. However, the differential efficacy of these two regimens in patients with CHB and coexisting MASLD, alongside their regulatory effects on metabolic parameters such as blood lipids and glucose, remains to be fully elucidated.
Therefore, this study aims to retrospectively analyze clinical data from patients with CHB and MASLD treated with PEG-IFNα-2b or NAs. By comparing the antiviral efficacy and the impact on metabolic parameters, including lipid and glucose profiles, between these two drug classes, this study seeks to provide clinical evidence for formulating individualized treatment strategies for this specific patient population.
Methods
Study Subjects and Treatment Grouping
Study Subjects
In this retrospective analysis, 174 patients with biopsy-confirmed MASLD and CHB were enrolled at Xiamen Hospital of Traditional Chinese Medicine between July 2019 and July 2024 were enrolled. This retrospective study was approved by the Ethics Committee of Xiamen Hospital of Traditional Chinese Medicine (approval No.: 2024-K08-22), which waived the requirement for written informed consent. To ensure patient data confidentiality, all medical records were anonymized and de-identified prior to data extraction. The study was conducted in full compliance with the ethical principles of the Declaration of Helsinki.
Treatment Protocols and Grouping
Patients were categorized into two cohorts based on the antiviral regimens they received for at least 48 weeks: the PEG-IFNα-2b group (n = 87) and the NAs group (n = 87). The PEG-IFN group comprised patients treated with pegylated interferon alfa-2b (Pegbing®; Xiamen Amoytop Biotech Co., Ltd., China), administered subcutaneously at a standard dose of 180 μg once weekly, either as monotherapy or in combination with NAs. Due to the retrospective nature of the data, the exact proportion of patients receiving PEG-IFNα-2b monotherapy versus combination therapy could not be reliably ascertained from the medical records; therefore, all PEG-IFN-treated patients were analyzed as a single group. This limitation is addressed in the Discussion. The NAs group consisted of patients who exclusively received continuous NAs monotherapy. The NAs utilized in this study included entecavir (ETV), tenofovir disoproxil fumarate (TDF), and tenofovir alafenamide (TAF), which were administered orally at standard daily doses.
Liver Biopsy and Evaluation of Curative Efficacy
Liver biopsies were performed to evaluate baseline histology and predict the efficacy of PEG-IFNα-2b therapy, and written informed consent for the procedure obtained from each patient. All liver samples were evaluated by a trained liver pathologist. Hepatic steatosis was assigned a grade of 0 (< 5% steatosis), 1 (5–33%), 2 (34–66%), or 3 (≥ 67%). Using the Scheuer scoring system, fibrosis was categorized into stages S0–S4, and necroinflammatory activity was categorized into grades G0-G4.
Clinical Data and Laboratory Tests
At enrollment, extensive clinical and anthropometric data were collected. The following information was assessed for each patient: age, sex, clinical history, medication history, alcohol consumption history, family history of hepatocellular carcinoma and liver cirrhosis, body mass index (BMI), and blood pressure. At the time of liver biopsy, patients’ clinical characteristics and vibration-controlled transient elastography (VCTE) data were recorded, along with levels of albumin (ALB), globulin (GLB), total bilirubin (TBIL), direct bilirubin (DBIL), total cholesterol (TC), triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), fasting blood glucose (FBG), uric acid (UC), alanine aminotransferase (ALT), aspartate aminotransferase (AST), gamma-glutamyl transferase (GGT), alpha-fetoprotein (AFP), des-gamma-carboxy prothrombin (DCP), hepatitis B virus DNA (HBV DNA) quantification, hepatitis B surface antigen (HBsAg) quantification, and hepatitis B e antigen (HBeAg) quantification. Pathological findings from liver biopsies were collected, including the degree of steatosis, grade of lobular inflammation, stage of fibrosis, and presence of hepatocellular ballooning. All blood tests were performed within 72 hours after the liver biopsy. All VCTE procedures were performed by two experienced physicians who had independently performed more than 10,000 examinations using the FibroScan 502 device (EchoSens, France). Liver stiffness measurement (LSM) results were reported in kPa, and controlled attenuation parameter (CAP) results were reported in dB/m.
Inclusion and Exclusion Criteria
Patients eligible for inclusion were (1) aged ≥ 18 years; (2) HBsAg positive for a minimum of 6 months and had received NAs and/or PEG-IFNα-2b therapy for at least 48 weeks; and (3) individuals with biopsy-confirmed MASLD.
Patients were excluded from the study if they exhibited (1) other concurrent liver diseases, including non-HBV viral hepatitis, primary biliary cholangitis, metabolic or hereditary liver diseases, drug-induced liver disease, or autoimmune liver diseases; (2) a history of alcohol use (≥ 40 or ≥ 20 g/day for males and females, respectively); (3) any laboratory or clinical findings consistent with decompensated liver disease; or (4) changed in their antiviral regimen during treatment or missing data at week 24 and week 48.
Statistical Analysis
Statistical analysis was performed using SPSS software (version 26.0). Continuous variables with a normal distribution were expressed as the mean ± standard deviation and compared between groups using the independent samples t-test. Non-normally distributed continuous variables were expressed as medians (interquartile range) and compared between groups using the Mann–Whitney U-test. Categorical variables were expressed as numbers (percentages) and compared between groups using the Chi-square test or Fisher’s exact test, as appropriate. Multivariable linear regression analysis was performed to evaluate the independent effect of the treatment regimen on changes in metabolic parameters, with adjustment for the baseline value of the corresponding parameter, age, sex, baseline HBeAg status, and baseline BMI. Baseline covariate balance between the two groups was achieved using inverse probability of treatment weighting (IPTW). Propensity scores were estimated via a multivariable logistic regression model incorporating the following baseline covariates: age, sex, body mass index (BMI), HBeAg status, HBV DNA level, HBsAg level, and fibrosis stage. Each participant was subsequently assigned a weight—1/propensity score for the PEG-IFN group and 1/(1 − propensity score) for the NA group—with weights truncated at the 99th percentile to attenuate the impact of extreme values. Following weighting, group differences in outcome measures were assessed using weighted linear regression models with treatment assignment as the sole independent variable; effect estimates were reported as regression coefficients (β) with corresponding 95% confidence intervals (CIs). A two-tailed P value < 0.05 was considered statistically significant. No a priori sample size calculation was performed, as this was a retrospective study enrolling all consecutive eligible patients within the study period. For the primary outcome (HBsAg seroclearance at week 48), the observed rate difference (9.2% vs 0%) had a 95% confidence interval of (3.2%, 15.2%), with the lower bound exceeding the null threshold of 0%, indicating sufficient precision for this estimate. For secondary metabolic endpoints, the 95% CIs (eg, LDL-C change: −0.995 to −0.523) excluded the null value, supporting adequate power to detect clinically meaningful differences.
Results
Patient Characteristics
No significant differences were observed between the two groups in terms of general characteristics, including age, sex, height, weight, BMI, blood pressure, alcohol consumption history, and family history (P > 0.05). Comparisons of VCTE parameters (CAP and LSM values), liver function tests, metabolic parameters (total cholesterol, triglycerides, fasting blood glucose, uric acid), virological markers (HBV DNA, HBsAg), and histopathological features (grade of steatosis, grade of lobular inflammation, stage of fibrosis, etc.) showed no statistically significant differences between the two groups (P > 0.05). The HBeAg-positive rate was significantly higher in the NAs group (70.1%) compared with the PEG-IFNα-2b group (43.7%), and the difference was statistically significant (P < 0.001) (Table 1), to address this and other baseline imbalances, an IPTW sensitivity analysis was performed (see Results Sensitivity Analysis With IPTW and Supplementary Table 1A).
Table 1.
Baseline Characteristics of Patients
| Variables | Total (n = 174) | PEG-IFNα-2b group (n = 87) | NA(s) group (n = 87) | P value |
|---|---|---|---|---|
| Age (years) | 38.00 (34.00, 44.75) | 37.00 (32.50, 42.00) | 39.00 (34.00, 46.50) | 0.094 |
| Sex | 0.163 | |||
| Male | 153 (87.9%) | 80 (92.0%) | 73 (83.9%) | |
| Female | 21 (12.1%) | 7 (8.0%) | 14 (16.1%) | |
| Height (cm) | 169.91 ± 7.05 | 170.37 ± 6.65 | 169.45 ± 7.44 | 0.391 |
| Weight (kg) | 73.50 (67.00, 80.45) | 73.50 (67.00, 79.20) | 74.50 (66.50, 82.35) | 0.463 |
| BMI (kg/m2) | 25.31 (23.73, 27.73) | 25.06 (23.17, 26.66) | 25.35 (24.02, 27.95) | 0.202 |
| BMI category | 0.480 | |||
| Underweight | 1 (0.6%) | 0 (0.0%) | 1 (1.1%) | |
| Normal | 49 (28.2%) | 28 (32.2%) | 21 (24.1%) | |
| Overweight | 84 (48.3%) | 41 (47.1%) | 43 (49.4%) | |
| Obese | 40 (23.0%) | 18 (20.7%) | 22 (25.3%) | |
| Systolic BP (mmHg) | 125.0 (116.0, 131.0) | 122.00 (116.00, 132.00) | 126.00 (117.50, 130.00) | 0.388 |
| Diastolic BP (mmHg) | 75.60 ± 9.38 | 74.63 ± 9.44 | 76.57 ± 9.28 | 0.173 |
| Concurrent MASLD | 173 (99.4%) | 87 (100.0%) | 87 (100.0%) | 1.000 |
| Family history of cirrhosis |
15 (8.6%) | 8 (9.2%) | 7 (8.0%) | 1.000 |
| Family history of HCC | 31 (17.8%) | 17 (19.5%) | 14 (16.1%) | 0.666 |
| History of alcohol consumption |
28 (16.1%) | 18 (20.7%) | 10 (11.5%) | 0.148 |
| VCTE-CAP (dB/m) | 267.0 (242.0, 297.0) | 267.00 (237.75, 288.75) | 269.00 (244.00, 308.00) | 0.343 |
| VCTE-LSM (kPa) | 6.75 (5.70, 8.70) | 6.80 (5.90, 8.30) | 6.60 (5.45, 10.20) | 0.778 |
| Albumin (g/L) | 45.00 (43.00, 46.08) | 45.00 (43.00, 47.00) | 44.00 (43.00, 46.00) | 0.138 |
| Globulin (g/L) | 30.00 (27.00, 32.75) | 30.00 (27.00, 32.50) | 30.00 (26.00, 32.50) | 0.887 |
| Total bilirubin (μmol/L) | 14.95 (10.93, 20.00) | 15.00 (11.50, 20.10) | 14.70 (10.80, 19.80) | 0.897 |
| Direct bilirubin (μmol/L) | 5.05 (3.32, 7.20) | 5.50 (3.95, 7.20) | 4.70 (3.05, 7.15) | 0.326 |
| TC (mmol/L) | 4.60 (4.00, 5.49) | 4.60 (3.96, 5.40) | 4.60 (4.05, 5.63) | 0.641 |
| TG (mmol/L) | 1.45 (1.07, 1.89) | 1.47 (0.99, 1.96) | 1.40 (1.11, 1.85) | 0.776 |
| HDL-C (mmol/L) | 1.06 (0.90, 1.34) | 1.06 (0.88, 1.33) | 1.07 (0.92, 1.35) | 0.404 |
| LDL-C (mmol/L) | 2.84 (2.29, 3.80) | 2.85 (2.33, 3.67) | 2.76 (2.21, 3.83) | 0.720 |
| FBG (mmol/L) | 5.10 (4.80, 5.47) | 5.00 (4.80, 5.30) | 5.20 (4.85, 5.75) | 0.021 |
| Uc (μmol/L) | 395.00 (332.00, 443.50) | 403.00 (339.50, 446.00) | 372.00 (318.05, 441.15) | 0.185 |
| ALT (U/L) | 57.50 (40.00, 101.75) | 50.00 (40.00, 105.00) | 60.00 (38.50, 100.00) | 0.679 |
| AST (U/L) | 37.00 (25.00, 63.00) | 33.00 (24.50, 58.50) | 41.00 (26.50, 67.50) | 0.273 |
| GGT (U/L) | 39.00 (28.00, 71.75) | 39.00 (25.00, 70.50) | 40.00 (28.50, 76.50) | 0.237 |
| AFP (ng/mL) | 2.70 (1.70, 4.28) | 2.44 (1.60, 3.85) | 2.80 (1.80, 4.55) | 0.073 |
| DCP (mAU/mL) | 21.00 (19.00, 25.00) | 21.00 (19.00, 26.50) | 21.00 (18.00, 24.50) | 0.234 |
| HBV DNA (log IU/mL) | 4.14 (2.80, 6.35) | 4.10 (2.58, 6.40) | 4.21 (2.87, 6.02) | 0.859 |
| HBsAg (IU/mL) | 2721.64 (607.03, 11,111.99) | 2424.60 (523.65, 10,878.31) | 3058.17 (684.88, 10,771.45) | 0.835 |
| HBeAg quantification (IU/mL) | 0.17 (0.00, 14.90) | 0.03 (0.00, 11.08) | 0.22 (0.02, 54.78) | 0.008 |
| HBeAg status | <0.001 | |||
| Negative | 75 (43.1%) | 49 (56.3%) | 26 (29.9%) | |
| Positive | 99 (56.9%) | 38 (43.7%) | 61 (70.1%) | |
| Histological steatosis grade | 0.144 | |||
| Mild | 135 (77.6%) | 62 (71.3%) | 73 (83.9%) | |
| Moderate | 31 (17.8%) | 20 (23.0%) | 11 (12.6%) | |
| Severe | 8 (4.6%) | 5 (5.7%) | 3 (3.4%) | |
| Lobular inflammation grade | 0.430 | |||
| 1 | 34 (19.5%) | 20 (23.0%) | 14 (16.1%) | |
| 2 | 119 (68.4%) | 59 (67.8%) | 60 (69.0%) | |
| 3 | 20 (11.5%) | 8 (9.2%) | 12 (13.8%) | |
| 4 | 1 (0.6%) | 0 (0.0%) | 1 (1.1%) | |
| Fibrosis stage | 0.733 | |||
| 0 | 4 (2.3%) | 2 (2.3%) | 2 (2.3%) | |
| 1 | 146 (83.9%) | 74 (85.1%) | 72 (82.8%) | |
| 2 | 15 (8.6%) | 7 (8.0%) | 8 (9.2%) | |
| 3 | 7 (4.0%) | 2 (2.3%) | 5 (5.7%) |
Note: Continuous variables are presented as medians (interquartile range) or mean ± standard deviation; categorical variables are presented as numbers (percentages).
Comparison of Antiviral Efficacy
HBsAg-Related Efficacy
The HBsAg seroclearance rates in the PEG-IFNα-2b group at weeks 24 and 48 were significantly higher than those in the NAs group (6.9% vs 0.0%; 9.2% vs 0.0%, respectively; P = 0.029 and P = 0.007) (Figure 1A). The proportions of patients achieving HBsAg <500 IU/mL (50.6% vs 20.7% at week 24; 56.3% vs 20.7% at week 48) and HBsAg <100 IU/mL (37.9% vs 10.3% at week 24; 37.9% vs 9.2% at week 48) were significantly higher in the PEG-IFNα-2b group compared with the NAs group at both time points (all P < 0.001) (Figure 1C, 1D). Furthermore, the PEG-IFNα-2b group demonstrated significantly greater reductions in log HBsAg levels from baseline to weeks 24 and 48 compared with the NAs group (0.838 vs 0.051 at week 24; 1.001 vs 0.101 at week 48; both P < 0.001) (Figure 1E).
Figure 1.
Comparison of virological responses between the PEG-IFNα-2b and NAs groups at weeks 24 and 48. (A) HBsAg seroclearance rates. (B) HBeAg seroconversion rates. (C) Proportions of patients achieving HBsAg < 500 IU/mL. (D) Proportions of patients achieving HBsAg < 100 IU/mL. (E) Reductions in log HBsAg, log HBV DNA, and HBeAg levels from baseline to weeks 24 and 48.
HBeAg Seroconversion
The HBeAg seroconversion rates at weeks 24 and 48 were 5.3% and 5.3% in the PEG-IFNα-2b group, compared with 16.4% and 14.8% in the NAs group, respectively. No statistically significant differences were observed between the two groups (P = 0.123 at week 24; P = 0.196 at week 48) (Figure 1B).
HBV DNA Reduction
No significant differences were found between the two groups in terms of the log HBV DNA reduction from baseline to weeks 24 and 48 (P = 0.584 at week 24; P = 0.782 at week 48) (Figure 1E).
Comparison of Metabolic Parameter Changes
The reductions in total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and BMI from baseline to weeks 24 and 48 were significantly greater in the PEG-IFNα-2b group compared with the NAs group. Additionally, the reduction in uric acid at week 24 and the reduction in CAP value at week 48 were also significantly greater in the PEG-IFNα-2b group (all P < 0.001). No significant differences were observed between the two groups in terms of changes in fasting blood glucose, uric acid reduction at week 48, or triglyceride levels (P > 0.05) (Table 2 and Table 3).
Table 2.
Multivariable Linear Regression Analysis of Changes in Metabolic Parameters at Week 24 Between PEG-IFNα-2b and NAs Treatment Groups
| Metabolic Parameters | Regression Coefficient (95% CI) | P value |
|---|---|---|
| Fasting glucose change at week 24 | −0.217 (−0.516 to 0.081) | 0.156 |
| Uric acid change at week 24 | −41.979 (−63.513 to −20.446) | <0.001 |
| Total cholesterol change at week 24 | −0.944 (−1.341 to −0.546) | <0.001 |
| Triglycerides change at week 24 | 0.082 (−0.220 to 0.384) | 0.596 |
| HDL-C change at week 24 | −0.162 (−0.242 to −0.083) | <0.001 |
| LDL-C change at week 24 | −0.584 (−0.801 to −0.368) | <0.001 |
| BMI change at week 24 | −2.066 (−2.888 to −1.243) | <0.001 |
| CAP change at week 24 | −4.189 (−9.308 to 0.931) | 0.111 |
Table 3.
Multivariable Linear Regression Analysis of Changes in Metabolic Parameters at Week 48 Between PEG-IFNα-2b and NAs Treatment Groups
| Metabolic Parameters | Regression Coefficient (95% CI) | P value |
|---|---|---|
| Fasting glucose change at week 48 | −0.302 (−0.666 to 0.063) | 0.107 |
| Uric acid change at week 48 | −4.108 (−27.038 to 18.822) | 0.726 |
| Total cholesterol change at week 48 | −0.802 (−1.088 to −0.516) | <0.001 |
| Triglycerides change at week 48 | 0.473 (−0.059 to 1.006) | 0.083 |
| HDL-C change at week 48 | −0.239 (−0.331 to −0.146) | <0.001 |
| LDL-C change at week 48 | −0.759 (−0.995 to −0.523) | <0.001 |
| BMI change at week 48 | −2.314 (−2.878 to −1.749) | <0.001 |
| CAP change at week 48 | −11.022 (−18.753 to −3.291) | 0.006 |
Comparison of Adverse Reactions
The PEG-IFNα-2b group exhibited a higher incidence of hematological adverse reactions, including leukopenia (83.9%), neutropenia (82.6%), thrombocytopenia (70.1%), and decreased hemoglobin (24.1%). Regarding liver function parameters, the incidences of elevated ALT (72.4%), elevated AST (73.6%), and elevated GGT (65.5%) in the PEG-IFNα-2b group were significantly higher than those in the NAs group (32.2%, 19.5%, and 16.1%, respectively), with statistically significant differences (all P < 0.001). No significant differences were observed between the two groups in the incidences of elevated alpha-fetoprotein or elevated des-gamma-carboxy prothrombin (P > 0.05) (Table 4).
Table 4.
Comparison of Adverse Reactions
| Parameters (n,%) | PEG-IFNα-2b group (n=87) | NAs group (n=87) | P value |
|---|---|---|---|
| Leukopenia | 73 (83.9%) | 0 (0.0%) | <0.001 |
| Neutropenia | 71 (82.6%) | 0 (0.0%) | <0.001 |
| Thrombocytopenia | 61 (70.1%) | 0 (0.0%) | <0.001 |
| Decreased hemoglobin | 21 (24.1%) | 0 (0.0%) | <0.001 |
| Elevated ALT | 63 (72.4%) | 28 (32.2%) | <0.001 |
| Elevated AST | 64 (73.6%) | 17 (19.5%) | <0.001 |
| Elevated GGT | 57 (65.5%) | 14 (16.1%) | <0.001 |
| Elevated AFP | 10 (11.5%) | 5 (5.8%) | 0.280 |
| Elevated DCP | 5 (5.8%) | 2 (2.3%) | 0.444 |
Sensitivity Analysis with IPTW
To validate the robustness of the primary findings against potential baseline imbalances, we conducted an IPTW sensitivity analysis. After IPTW adjustment, all baseline covariates were well balanced between the two groups, with standardized mean differences (SMDs) for all variables—including HBeAg status, HBV DNA, HBsAg, and fibrosis stage—falling well below the conventional threshold of 0.1 (Supplementary Table 1A). Specifically, the SMD for HBeAg-negative status was −0.010, for HBV DNA was 0.006, and for HBsAg was 0.013, indicating that confounding by these factors was effectively minimized. The IPTW-adjusted analyses confirmed the primary conclusions. The PEG-IFNα-2b group maintained significantly higher HBsAg seroclearance rates and demonstrated significantly greater reductions in total cholesterol, LDL-cholesterol, and BMI compared with the NAs group, with effect estimates (β and 95% CIs) consistent with those derived from the primary multivariable regression models (detailed data are presented in Supplementary Table 1B-1 and 1B-2).
Discussion
The co-existence of CHB and MASLD is increasingly common, and their synergistic effect can accelerate liver fibrosis progression while significantly increasing the risk of cirrhosis and hepatocellular carcinoma5,10. Furthermore, concurrent metabolic disturbances (such as hyperlipidemia and hyperuricemia) exacerbate the cardiovascular disease burden and all-cause mortality in these patients3,11. Therefore, an ideal antiviral strategy for patients with CHB-MASLD should not only pursue a virological response but also consider improvements in metabolic parameters. This retrospective study analyzed 174 patients with biopsy-confirmed CHB and MASLD, comparing the efficacy of 48-week treatment with PEG-IFNα-2b versus NAs. The findings revealed that PEG-IFNα-2b demonstrated significant advantages in achieving HBsAg seroclearance and improving multiple metabolic parameters.
The results of this study showed that after 48 weeks of treatment, the HBsAg seroclearance rate in the PEG-IFNα-2b group reached 9.2%, which was significantly higher than the 0% rate observed in the NAs group (P = 0.007). Additionally, the PEG-IFNα-2b group exhibited significant advantages in both the magnitude of the HBsAg quantification reduction and the rate of achieving low-level HBsAg (<100 IU/mL). This finding reinforces the established central role of interferon in pursuing a functional cure for CHB. The data from this study suggest that hepatic steatosis does not attenuate the immunomodulatory effects of PEG-IFNα-2b. For patients with CHB-MASLD who have favorable baseline characteristics and aim for clinical cure, PEG-IFNα-2b should remain one of the preferred treatment options. Both groups demonstrated comparable HBV DNA suppression, indicating that NAs remain stable and reliable in inhibiting viral replication. However, interferon-based regimens show greater potential in achieving the higher therapeutic goal of HBsAg seroclearance. This is also consistent with the results in the CHB-monoinfected population: studies by Lim et al12 and Hu et al13 have confirmed that in NAs-treated CHB patients, the PEG-IFNα-2b strategy can achieve an HBsAg clearance rate of approximately 8–10% and significantly increase the conversion rate to HBsAg < 100 IU/mL (around 30%), demonstrating a far superior efficacy compared to NAs monotherapy.
A key finding of this study is the significant metabolic benefit associated with PEG-IFNα-2b therapy. Multivariable regression analysis, after adjusting for baseline values and confounding factors, revealed that the reductions in total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), and BMI at week 48 were significantly greater in the PEG-IFNα-2b group compared with the NAs group.
Regarding alterations in the lipid profile, we observed that PEG-IFNα-2b significantly reduced TC and LDL-C levels. A recent review published in Nature Reviews Rheumatology indicated that type I interferons can inhibit the activity of key enzymes involved in cholesterol biosynthesis through the JAK1 signaling pathway14. As a long-acting type I interferon, PEG-IFNα-2b may directly intervene in lipid metabolism through this same mechanism, thereby improving the pro-atherogenic lipid profile in patients with CHB-MASLD and potentially reducing their risk of cardiovascular events.
Furthermore, a significant reduction in BMI was observed in the PEG-IFNα-2b group (β = −2.314, P < 0.001). Previous studies have confirmed that weight loss is associated with improvement in hepatic steatosis in a dose-dependent manner15,16. Although interferon-related gastrointestinal symptoms (such as nausea and decreased appetite) may contribute to the weight loss in the early stages of treatment, the sustained nature of weight reduction observed in this study suggests the involvement of additional mechanisms. The Pediatric Study of Hepatitis C (PEDS-C) trial previously reported that interferon may directly affect growth and body composition in children,17 leading to the hypothesis that in adults, interferon may exert effects through the modulation of energy expenditure or lipolytic pathways.
Furthermore, the controlled attenuation parameter (CAP), an objective indicator of hepatic fat content, demonstrated a significant decrease in the PEG-IFNα-2b group at week 48 (β = −11.022 dB/m, P = 0.006), whereas no notable change was observed in the NAs group. These findings suggest that PEG-IFNα-2b treatment may be associated with the regression of hepatic steatosis. This dual antiviral and anti-steatogenic effect may be of substantial importance in halting the progression to end-stage liver disease in patients with CHB-MASLD.
It is noteworthy that this study observed a significant decrease in HDL-C levels in the PEG-IFNα-2b group, consistent with findings from the AIDS Clinical Trials Group A5178 study, which reported comprehensive lipid reductions in HCV/HIV-coinfected patients receiving interferon-based therapy18. HDL-C is generally regarded as a cardiovascular protective factor, and the long-term clinical implications of its decline warrant attention. However, given the concomitant significant reductions in TC and LDL-C, along with overall weight loss, the trend in the non-HDL-C/HDL-C ratio—a more comprehensive indicator of cardiovascular risk—requires further evaluation. Additionally, whether these lipid alterations are reversible, returning to baseline levels after treatment discontinuation, remains to be elucidated through long-term follow-up data.
In terms of safety, the PEG-IFNα-2b group indeed exhibited a higher incidence of adverse events, particularly hematological toxicities (leukopenia, neutropenia, and thrombocytopenia) and transient transaminase elevations (ALT/AST elevation rates exceeding 70%). However, the majority of adverse events were mild to moderate in severity and did not lead to hepatic decompensation. Sonneveld et al categorized ALT flares during PEG-IFNα-2b treatment into “host-induced flares” and “virus-induced flares,” finding that the former—characterized by an ALT increase accompanied by a subsequent decline in HBV DNA—was associated with wild-type virus infection. In these patients, the subsequent HBsAg clearance rate reached up to 64%, serving as a predictor of favorable treatment outcomes19. Fontana et al20 emphasized in the liver safety assessment framework for clinical trials of novel CHB therapies that anticipated immune-mediated aminotransferase flares should be distinguished from drug-induced liver injury (DILI). Although direct evidence specifically for patients with CHB with MASLD is currently lacking, based on the aforementioned mechanisms, we propose that the early treatment-associated aminotransferase elevation in the context of CHB-MASLD may reflect enhanced immune clearance activity induced by interferon, rather than drug-induced liver injury. Nevertheless, enhanced monitoring remains necessary in clinical practice, particularly for patients with low baseline blood cell counts or significant inflammatory activity.
This study has several limitations. First, the retrospective design inevitably introduces selection bias. Although multivariable regression analysis was performed to adjust for known confounding factors, we cannot completely exclude the influence of uneven lifestyle interventions (such as dietary control and physical activity) on metabolic parameters. Second, the follow-up duration was limited to 48 weeks, precluding the assessment of the durability of HBsAg seroclearance after treatment discontinuation and the long-term maintenance of metabolic benefits. Third, the lack of post-treatment histopathological data or MRI-PDFF as gold standard measures may introduce some bias in the evaluation of hepatic fat content, which relied solely on CAP values. Fourth, the PEG-IFNα-2b group included both monotherapy and combination with NAs, and we were unable to separate these subgroups due to data limitations. Thus, the relative contribution of each component to the observed efficacy remains unclear. Future prospective studies with predefined treatment allocation are warranted to address this question.
Future prospective, multicenter randomized controlled trials with extended follow-up periods are warranted to observe clinical endpoints (such as cardiovascular events and HCC incidence) and to further explore the specific molecular mechanisms underlying interferon-mediated metabolic improvements.
Acknowledgments
The authors thank and acknowledge all the clinical and research staff from the Liver Disease Center of Xiamen Hospital of Traditional Chinese Medicine.
Funding Statement
This work was supported by the National Natural Science Foundation of China (Nos. 82174141 and 82374353), Fujian Provincial Natural Science Foundation General Project (2025J011451), Support Project for Young Qihuang Scholars of State Administration of Traditional Chinese Medicine (No. 200 (2021) and No. 256 (2022)), Natural Science Foundation of Fujian Province, General Program (Grant No. 2025J011451), Xiamen Municipal Health Commission, Science and Technology Plan Project for High-Quality Health Development (Youth Research Project, Grant No. 2024GZL-QN120), Xiamen Science and Technology Planning Project (3502Z20224018), Xiamen Medical and Health Guidance Project (3502Z20224ZD1166), and Sixth Batch of Traditional Chinese Medicine Reserve Talent Project in Xiamen (Xiamen Traditional Chinese Medicine) (2022) (No. 136).
Abbreviations
CHB, chronic hepatitis B; MASLD, metabolic dysfunction-associated steatotic liver disease; PEG-IFNα-2b, pegylated interferon alpha-2b; NAs, versus nucleos(t)ide analogues; LSM, liver stiffness measurement; CAP, controlled attenuation parameter; HBV, hepatitis B virus; BMI, body mass index; VCTE, vibration-controlled transient elastography; ALB, albumin; GLB, globulin; TBIL, total bilirubin; DBIL, direct bilirubin; TC, total cholesterol; TG, triglycerides; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol; FBG, fasting blood glucose; UC, uric acid; ALT, alanine aminotransferase; AST, aspartate aminotransferase; GGT, gamma-glutamyl transferase; AFP, alpha-fetoprotein; DCP, des-gamma-carboxy prothrombin; HBV DNA, hepatitis B virus DNA; HBsAg, hepatitis B surface antigen; HBeAg, hepatitis B e antigen.
Data Sharing Statement
The data underlying the results presented in the study are available within the manuscript.
Author Contributions
Yaoyu Liu, Hanlong Wang and Xiaoting Zheng contributed equally to this work and are co-first authors. All authors have seen the manuscript and approved its submission. All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work. Shaodong Chen and Huiqing Liang are the joint corresponding authors of this work.
Disclosure
The authors declare no conflicts of interest.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data underlying the results presented in the study are available within the manuscript.