Its Correlation With HBV DNA
Its Correlation With HBV DNA
Its Correlation With HBV DNA
OPEN
Abstract
There are approximately 2 billion HBV-infected individuals worldwide, and approximately 1.87% to 7% of these individuals are
copositive for HBsAg and HBsAb.
Our study detected hepatitis B virus pgRNA (HBV RNA) levels in HBsAg and HBsAb copositive patients and then analyzed the
correlation with HBV DNA, HBsAg, ALT, and AST levels. A total of 149 HBsAg and HBsAb copositive patients were identified from
66,617 outpatients.
HBV RNA, HBV DNA, HBsAg, ALT, and AST serum levels were significantly different in different natural phases of HBV infection
(immune tolerance phase, immune clearance phase, low replication phase, and reactivation phase) with statistical significance
(P < .01). HBV RNA levels were positively correlated with HBV DNA, HBsAg, ALT, and AST levels. HBV RNA and HBV DNA levels
were significantly increased in the HBeAg-positive group (66 patients) compared with the HBeAg-negative group (83 patients)
(P < .01). In the HBeAg-positive group, HBV RNA levels were positively correlated with HBV DNA and HBsAg levels. In the HBeAg-
negative group, HBV RNA levels were positively correlated with HBV DNA. Serum HBV RNA levels were positively correlated with
HBV DNA, HBsAg, ALT, and AST levels.
HBV RNA could be used as a virological indicator for antiviral therapy in HBsAg and HBsAb copositive hepatitis B patients.
Abbreviations: cccDNA = covalently closed DNA, HBV RNA = hepatitis B virus pgRNA, NAs = nucleot(s)ide and its analogs,
pgRNA = pregenomic RNA, VR = virological response.
Keywords: copositive patients, HBV DNA, HBV RNA, hepatitis B virus
1. Introduction
Editor: Wenyu Lin. Hepatitis B virus (HBV) infection is a serious public health
This study was supported by Basic Research and Frontier Exploration Program problem, and there are approximately 2 billion HBV-infected
of Chongqing Scientific and Technological Committee (Grant/Award Number: individuals worldwide. It is estimated that approximately
cstc2018jcyjAX0748).
786,000 people die from chronic HBV infection-associated
The authors have no conflicts of interest to disclose. cirrhosis or hepatocellular carcinoma every year.[1–4] In recent
The datasets generated during and/or analyzed during the current study are years, HBV serological patterns have changed due to mutations
available from the corresponding author on reasonable request. All data
in the HBV gene, optimization of detection reagents, improve-
generated or analyzed during this study are included in this published article [and
its supplementary information files]. ments in test methods, and drug resistance caused by long-term
a
Department of Laboratory Medicine, The First Affiliated Hospital of Chongqing
medication. As a special serological patterns of HBV infection,
Medical University, Chongqing, China, b Department of Gastroenterology, The the rate of HBsAg and HBsAb copositive is increasing. It has been
First Affiliated Hospital of Chongqing Medical University, Chongqing, China, reported that HBsAg and HBsAb copositive appear in approxi-
c
Department of General Surgery, Jinshan Hospital, The First Affiliated Hospital of mately 1.87% to 7% of HBV-infected patients[5–7] and many
Chongqing Medical University, Chongqing, China.
∗
studies showed that this type of HBV-infection have some special
Correspondence: Wenxian You, Department of Gastroenterology, The First features.[8,9]
Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
(e-mail: fs_ywx@163.com).
In the Guidelines of Prevention and Treatment for Chronic
Hepatitis B (2015) issued by the Chinese Society of Hepatology
Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.
This is an open access article distributed under the terms of the Creative and Chinese Society of Infectious Diseases, it is stated that if a
Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is sustained off-treatment response cannot be obtained at the basic
permissible to download, share, remix, transform, and buildup the work provided endpoint of CHB treatment, the long-term virological response
it is properly cited. The work cannot be used commercially without permission (VR) should be maintained with antiviral therapy to continue
from the journal.
suppression so that HBV DNA cannot be detected.[10] However,
How to cite this article: Xiang Y, Yang Y, Chen P, Lai X, Shi S, Li S, You W.
this situation cannot be achieved with the use of existing reagents
Analysis of serum hepatitis B virus RNA levels among HBsAg and HBsAb
copositive patients and its correlation with HBV DNA. Medicine 2021;100:40 for HBV DNA. HBV covalently closed DNA (cccDNA) only
(e27433). exists in the nucleus of infected hepatocytes and cannot be
Received: 10 February 2021 / Received in final form: 7 September 2021 / damaged by existing antiviral drugs, and a high proportion of
Accepted: 14 September 2021 virological rebound and disease relapse often occur after drug
http://dx.doi.org/10.1097/MD.0000000000027433 withdrawal.[11] Studies have shown that it is difficult to clinically
1
Xiang et al. Medicine (2021) 100:40 Medicine
cure CHB due to the existence of cccDNA.[12,13] However, the HBsAg and HBsAb copositive samples were identified. The
detection of cccDNA requires liver biopsy, which is invasive and following criteria for reactivity were employed: HBsAg > 0.04 IU/
not applicable in clinical practice. The disappearance of HBV mL, HBsAb > 10.00 mIU/mL, HBeAg > 1 S/CO, HBeAb < 1 S/CO
DNA only indicates that the reverse transcription of the virus is and HBcAb > 1 S/CO.
effectively inhibited and cannot reflect the status of transcrip- Serum ALT and AST levels were quantitatively detected by the
tional activity of cccDNA. Therefore, it is urgent to identify a new rate method using a Hitachi RL7600 automatic biochemical
serological marker to replace cccDNA in the clinic. In recent analyzer with the following reference intervals: ALT, 7 to 40 U/L;
years, it has been reported that HBV pregenomic RNA (HBV AST, 13 to 40 U/L.
RNA), which is produced from the transcription of cccDNA in HBV B, C, and D genotypes were detected by Cobas 480 real-
the nucleus of infected hepatocytes, exists in the serum or plasma time fluorescent PCR (Roche, USA) using an HBV genotyping kit
of HBV-infected patients. The envelope of nucleocapsid- (PCR-fluorescent probe method, Triplex International Bioscien-
encapsulated HBV RNA was obtained in the absence of reverse ces Co., Ltd., China).
transcription, which was then released from the infected HBV DNA load was detected by Cobas 480 real-time
hepatocytes into serum or plasma where it was detected. HBV fluorescent PCR (Roche, USA) using a Hepatitis B Virus Nucleic
RNA levels in serum reflect the expression levels of cccDNA and Acid Kit (PCR-fluorescent probe method, Sansure Biotech Co.,
its transcriptional activity.[14–16] Ltd., China) with a lower limit of detection of 1.0 102 IU/mL.
Above all, in this study, we selected the samples which HBsAg HBV RNA load was detected by Cobas 480 real-time
and HBsAb were copositive. The levels of HBV RNA, HBV fluorescent PCR (Roche, USA) using a Hhepatitis B virus pgRNA
DNA, HBsAg, ALT and AST in different natural phases of (HBV RNA) Kit (PCR-fluorescent probe method, Hotgen Biotech
disease were compared. The correlations between HBV RNA and Co., Ltd., China) with a lower limit of detection of 3.0 102
HBV DNA, HBsAg, ALT, and AST were analyzed as well as the copies/mL.
influence of HBeAg expression on HBV RNA, providing new
virological indicators for antiviral therapy in patients with
2.3. Assignment of HBV-infected patients to different
hepatitis B.
phases
According to the Guidelines of Prevention and Treatment for
2. Materials and methods
Chronic Hepatitis B (2015), the natural history of HBV infection
2.1. Patients and subjects can be divided into 4 phases: immune tolerance phase, immune
clearance phase, inactive or low replication phase, and viral
The results of HBV serological marker tests (HBsAg, HBsAb,
reactive phase. The immune tolerance phase is characterized
HBeAg, HBeAb, and HBcAb) in 66,617 outpatients from the
positive HBsAg, positive HBeAg, HBV DNA > 1 106 IU/mL, and
First Affiliated Hospital of Chongqing Medical University from
normal ALT levels; the immune clearance phase is characterized by
May 2017 to May 2018 were analyzed. A total of 149 HBsAg
positive HBsAg, positive HBeAg, HBV DNA > 2 103 IU/mL, and
and HBsAb copositive patients (without virus treatment) aged 22
continuous or intermittent increases in ALT levels; the inactive or
to 62 years (median, 32) were identified and divided into an
low replication phase is characterized by negative HBeAg, positive
HBeAg-positive group (66 patients) and an HBeAg-negative
anti-HBe, HBV DNA < 1 103 IU/mL, and normal ALT levels;
group (83 patients) based on HBeAg detection results. Serum
and the viral reactive phase is characterized by negative HBeAg,
HBV RNA, HBV DNA, ALT, and AST levels were analyzed in
positive anti-HBe, HBV DNA > 1 103 IU/mL, and continuous or
these patients. Only 90 of the 149 HBsAg and HBsAb copositive
repeated increases in ALT levels.
patients could be assigned to different phases (11 patients were in
the immune tolerance phase, 31 patients in the immune clearance
phase, 15 patients in the low replication phase and 33 patients in 2.4. Statistical methods
the reactive phase). Clinical data on all subjects were collected by Data in the study were analyzed with SPSS 17.0 software. The X2
questionnaires and by reviewing medical records, and informed test was used for enumeration data that did not conform to a
consent was obtained from all subjects. All procedures of this normal distribution. The results are described statistically by the
study were approved by the Ethics Committee of the First median (interquartile range) [M (P25–P75)]. The Mann–Whitney
Affiliated Hospital of Chongqing Medical University. U test was used for between-group comparisons, and the
Patients were eligible for the study if they were diagnosed with Kruskal–Wallis H test was used for multigroup comparisons.
CHB infection based on the diagnostic criteria in accordance with Spearman correlation analysis was also used with a P-value <.05
the Guidelines of Prevention and Treatment for Chronic being statistically significant.
Hepatitis B (2015) issued by the Chinese Society of Hepatology
and Chinese Society of Infectious Diseases; did not have other
hepatitis virus disease and HIV infections; did not have other liver 3. Results
diseases (such as autoimmune hepatitis and alcoholic hepatitis,
3.1. Description of common clinical characteristics
etc); and had not recently received immunosuppressants.
Among 149 HBsAg and HBsAb copositive patients, the levels of
HBsAg, HBV RNA, HBV DNA, ALT, and AST are expressed as
2.2. Detection of indicators
the median (interquartile range) [M (P25–P75)]. In total, 149
HBV serological markers (HBsAg, HBsAb, HBeAg, HBeAb, and HBsAg and HBsAb copositive patients were divided into the
HBcAb) were detected by chemiluminescence microparticle HBeAg-positive group (66 patients, 44.30%) and HBeAg-
immunoassay using an ARCHITECT i2000SR Automatic negative group (83 patients, 55.70%) based on the results of
Chemiluminescence Immunoanalyzer (Abbott, USA), and the HBeAg detection, as shown in Table 1.
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Xiang et al. Medicine (2021) 100:40 www.md-journal.com
Table 2
Analysis of HBV genotype.
∗
HBV genotypes n HBeAg positive group HBeAg negative group X2 P-value
Genotype B 141 (94.63%) 59 (89.39%) 82 (98.79%) 6.395 <.01
Genotype C 8 (5.37%) 7 (1.61%) 1 (1.21%)
In total 149 66 83 – –
∗
Categorical variables: chi-squared test, genotype distribution P < .05.
Table 3
Analysis of the effect of HBeAg on HBV RNA.
Indicators HBeAg positive group HBeAg negative group U/X2 P-value†
Number of patients n 66 (44.30%) 83 (55.70%) – –
Age (yr) 42.09 ± 16.15 52.88 ± 14.03 73.06 .043
Male n (%) 40 (60.6%) 46 (55.42%) 0.41 .525
Female n (%) 26 (39.4%) 37 (44.58%)
∗
HBV RNA (LOG IU/mL) 3.272.24, (4.34) 1.17 (0.00, 2.80) 1161.50 .000
∗∗
HBV DNA (LOG IU/mL) 5.61 (4.88, 6.69) 3.75 (2.98, 5.00) 1080.00 .000
HBsAg (IU/mL) 217.07 (43.72, 8038.54) 160.41 (18.34, 1444.51) 2288.00 .085
ALT (U/L) 39.50 (21.00, 72.00) 30.00 (20.00, 59.00) 2233.00 .053
AST (U/L) 35.00 (21.75, 72.50) 30.00 (23.00, 60.00) 2382.00 .172
† ∗ ∗∗
Categorical variables: chi-squared test; continuous variables: U test. HBV RNA: P < .01, HBV DNA, P < .01).
Table 4
Analysis of different natural phases of HBsAg and HBsAb co-positive patients.
Clinical Phases n HBV RNA (LOG copies/ml) HBV DNA (LOG IU/ml) HBsAg (IU/ml) ALT (U/L) AST (U/L)
Immune tolerance phase 11 5.04 (4.61, 5.65) 7.78 (6.27, 8.23) 12567.24 (193.27, 25,000.00) 28 (18, 35) 21 (20, 31)
Immune clearance phase 31 2.92 (1.99, 3.84) 5.58 (5.09, 6.45) 187.42 (40.49, 1454.56) 67 (41, 152) 71 (41, 141)
Low replication phase 15 0.00 (0.00, 1.38) 2.57 (2.34, 2.86) 62.13 (2.18, 998.41) 23 (16, 30) 25 (23, 27)
Viral reactive phase 33 2.68 (0.00, 3.11) 5.26 (4.10, 6.00) 687.65 (51.07, 2204.77) 62 (37, 90) 60 (37, 83)
H – 35.73 52.43 11.71 39.21 40.46
∗ ∗∗ ∗∗∗ ∗∗∗∗ ∗∗∗∗∗
P-value† – .00 .00 .01 .00 .00
† ∗ ∗∗ ∗∗∗ ∗∗∗∗ ∗∗∗∗∗
Continuous variables: H test, HBV RNA: P < .01; HBV DNA: P < .01; HBsAg: P < .01; ALT: P < .01; AST P < .01.
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Xiang et al. Medicine (2021) 100:40 Medicine
Figure 1. A–D Correlation of HBV RNA, HBV DNA, HBsAg, ALT, and AST levels. A, HBV RNA levels were positively correlated with HBV DNA (correlation efficient
r = 0.667, P = .000). B, HBsAg (correlation efficient r = 0.330, P = .000). C, ALT (correlation efficient r = 0.263, P = .001). D, AST (correlation efficient r = 0.218,
P = .007).
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Xiang et al. Medicine (2021) 100:40 www.md-journal.com
Table 6 P < .01; H = 52.43, P < .01; H = 11.71, P < .01; H = 39.21,
Correlation between HBV RNA and HBV DNA, HBsAg, ALT, AST in P < .01; H = 40.46, P < .01). HBV RNA, HBV DNA, and HBsAg
HBeAg positive group. levels in the immune tolerance phase were significantly increased
∗
Indicators Spearman correlation coefficient r P-value compared with those in the immune clearance phase, low
∗ replication phase and viral reactive phase (P < .01). HBsAg and
HBV DNA (LOG IU/mL) 0.595 .000
∗∗ HBsAb copositive patients who were in the viral reactive phase
HBsAg (IU/mL) 0.508 .000
ALT (U/L) 0.051 .687 were the most prevalent, accounting for 36.67%. This finding
AST (U/L) 0.128 .304 suggests that new HBV virological markers are in great need to
∗ ∗∗
monitor antiviral therapy in HBsAg and HBsAb copositive
Spearman correlation test HBV DNA: P < .01; HBsAg: P < .01. patients. In addition, with the advancement of different natural
phases, HBV RNA levels gradually decreased with decreasing
HBV DNA levels during immune tolerance, immune clearance
Table 7 and the low replication phase. Therefore, the combined detection
Correlation between HBV RNA and HBV DNA, HBsAg, ALT, AST in of HBV RNA, HBV DNA and other indicators has important
HBeAg negative group. clinical significance in the assignment of CHB patients to different
∗ phases, and the judgment of their condition and can provide a
Indicators Spearman correlation coefficient r P-value
∗ more reliable clinical basis for antiviral therapy in CHB patients.
HBV DNA (LOG IU/mL) 0.530 .000 In this study, the following correlation analysis results between
HBsAg (IU/mL) 0.117 .294 HBV RNA levels and HBV DNA, HBsAg, ALT, and AST levels in
∗∗
ALT (U/L) 0.433 .000
∗∗∗ the 149 HBsAg and HBsAb copositive patients were noted: serum
AST (U/L) 0.446 .000
HBV RNA levels were all positively correlated with HBV DNA
∗ ∗∗ ∗∗∗
Spearman correlation test HBV RNA: P < .01; ALT: P < .01; AST P < .01. (correlation efficient r = 0.667, P = .000), HBsAg (correlation
efficient r = 0.330, P = .000), ALT (correlation efficient r = 0.263,
(X2 = 6.395, P < .01) was noted in both the HBeAg-positive and P = .001) and AST levels (correlation efficient r = 0.218, P = .007).
HBeAg-negative groups. The best correlation was noted between HBV RNA levels and
Currently, nucleot(s)ide and its analogs (NAs) are widely used HBV DNA levels, which is consistent with previous studies.[29–30]
in the antiviral therapy of CHB. Mechanistically, these agents Therefore, HBV RNA can be used as a potential virological
control the reverse transcription of HBV (inhibiting viral DNA marker to assess the efficacy of antiviral therapy in CHB patients.
polymerase proteins with reverse transcription activity) and A recent study indicated that HBV RNA may exhibit a fast and
inhibit the synthesis of DNA to play an antiviral role. However, significant decline that correlates with treatment response and
NAs cannot eradicate cccDNA in the nucleus of hepatocytes, but HBsAg loss at long-term follow-up during PEG-IFN treatment
cccDNA levels were evident. Its transcriptional activity is the for HBeAg-negative CHB.[31] In addition, HBeAg expression
main factor that impedes clinical cure in CHB patients through levels impacted HBV RNA and HBV DNA expression levels; in
antiviral therapy. The guidelines define HBV DNA levels below other words, HBV RNA and HBV DNA expression levels were
the lower limit of detection in serum as VR and use it as one of the higher in the HBeAg-positive group than in the HBeAg-negative
treatment endpoints for drug withdrawal.[23–26] Virological group with a statistically significant difference (HBV RNA: U =
rebound occurs in many CHB patients after drug withdrawal 1161.50, P < .01; HBV DNA: U = 1080.00, P < .01). In the
for half a year or more when HBV DNA levels are below the HBeAg-positive group, HBV RNA levels were positively
lower limit of detection, leading to disease recurrence.[11] The correlated with HBV DNA (correlation coefficient r = 0.595,
disappearance of HBV DNA only indicates that the reverse P = 0.000) and HBsAg (correlation coefficient r = 0.508, P = .000)
transcription of HBV was effectively inhibited and does not levels. In the HBeAg-negative group, HBV RNA levels were
reflect the transcription status of cccDNA. positively correlated with HBV DNA levels (correlation coeffi-
Therefore, it is urgent to identify a new HBV virological cient r = 0.530, P = .000). Studies have shown that HBV RNA
marker to evaluate the efficacy of antiviral therapy in CHB levels are independently associated with HBeAg status, ALT
patients. levels, HBV genotype and basal core promoter mutations,
In 1996, German scholars found the presence of HBV RNA in especially the status of HBeAg, which is the most relevant factor
the serum of chronic HBV-infected patients.[27] HBV RNA in in HBV RNA levels (probably in high transcriptional activity).[29]
serum is pregenomic RNA (pgRNA) that has not undergone Therefore, HBeAg status affects HBV RNA expression. In our
reverse transcription. These pgRNAs exist in the nucleocapsid of study, in the HBeAg-negative group, ALT and AST with HBV
mature viral particles and are called “HBV RNA virus-like RNA below LLD are normal, ALT and AST with higher HBV
particles”.[16,28] Detection of HBV RNA levels in serum or RNA are >2 ULN, this is why HBV RNA levels were positively
plasma is of great significance to the auxiliary diagnosis of HBV correlated with AST/ALT. This result was similar with another
infection, the monitoring of therapeutic effects of NAs on CHB study.[32] In the future, we will increase the sample capacity for
patients and the prediction of drug withdrawal. follow-up research and explore the potential mechanism.
Only 90 of the 149 HBsAg and HBsAb copositive patients HBV RNA could be used as a virological indicator for antiviral
could be assigned to different phases according to their natural therapy in HBsAg and HBsAb copositive patients with hepatitis
course of disease. Among them, 11 patients (12.22%) were in the B; HBeAg expression impacted the expression of HBV RNA. We
immune tolerance phase, 31 (34.44%) were in the immune believe that the real VR should be the absence of DNA viruses and
clearance phase, 15 (16.67%) were in the low replication phase RNA viruses. Especially when receiving NAs, the criterion for
and 33 (36.67%) were in the viral reactive phase. HBV RNA, judging VR should be that both HBV DNA and RNA levels in
HBV DNA, HBsAg, ALT and AST levels were significantly serum are below the lower limit of detection. To correctly assess
different in different natural phases of HBV infection (H = 35.73, the therapeutic effect of antiviral therapy on HBsAg and HBsAb
5
Xiang et al. Medicine (2021) 100:40 Medicine
copositive patients and their disease progression, quantitative [14] Jansen L, Kootstra NA, van Dort KA, et al. Hepatitis B virus pregenomic
RNA is present in virions in plasma and is associated with a response to
detection of HBV RNA levels combined with the simultaneous
pegylated interferon alfa-2a and nucleos (t) ide analogues. J Infect Dis
detection of HBV DNA and HBsAg levels and HBV genotypes is 2016;213:224–32.
recommended as the clinical basis for the assessment. Using the [15] Wooddell CI, Yuen MF, Chan HLY, et al. RNAi-based treatment of
method, we provide better ideas for the clinical treatment of CHB chronically infected patients and chimpanzees reveals that
and a more effective clinical basis. integrated hepatitis B virus DNA is a source of HBsAg. Sci Transl
Med 2017;9:112.
[16] Wang J, Shen T, Huang X, et al. Serum hepatitis B virus RNA is
Author contributions encapsidated pregenome RNA that may be associated with persistence of
viral infection and rebound. J Hepatol 2016;65:700–10.
Conceptualization and Supervision: Wenxian You. [17] Severine Margeridon, Alain Lachaux, Christian Trepo. A quasi-
Data Curation: Yang Yang, Shuang Li. monoclonal anti-HBs response can lead immune escape of ‘wild-type’
hepatitis B virus. J Gen Virol 2005;86:1687–93.
Formal Analysis and Manuscript writing: Yu Xiang. [18] Mathet VL, Feld M, Espinola L, et al. Hepatitis B virus S gene mutants in
Methodology: Pu Chen, Xiaofei Lai, Shan Shi. a patient with chronic active hepatitis with circulating anti-HBs
Project administration: Wenxian You. antibodies. J Med Virol 2003;69:18–26.
Writing – original draft: Yu Xiang. [19] Mesenas SJ, Chow WC, Zhao YI, et al. Wild-type and ‘a’epitope variants
in chronic hepatitis B virus carriers positive for hepatitis B surface antigen
Writing – review & editing: Yu Xiang.
and antibody. J Gastroenterol Hepatol 2002;17:148–52.
[20] Lada O, Benhamou Y, Poynard T, et al. Coexistence of hepatitis B surface
References antigen (HBs Ag) and anti-HBs antibodies in chronic hepatitis B
virus carriers: influence of “a” determinant variants. J Virol 2006;80:
[1] Nelson NP, Easterbrook PJ, McMahon BJ. Epidemiology of hepatitis B 2968–75.
virus infection and impact of vaccination on disease. Clin Liver Dis [21] Tsuge M, Murakami E, Imamura M, et al. Serum HBV RNA and HBeAg
2016;20:607–28. are useful markers for the safe discontinuation of nucleotide analogue
[2] Ott JJ, Stevens GA, Groeger J, Wiersma ST. Global epidemiology of treatments in chronic hepatitis B infections. J Gastroenterol
hepatitis B virus infection: new estimates of age-specific HBsAg 2013;48:1188–204.
seroprevalence and endemicity. Vaccine 2012;30:2212–9. [22] Huang YW, Chayama K, Kao JH, et al. Detectability and clinical
[3] Mohd HK, Groeger J, Flaxman AD, Wiersma ST. Global epidemiology significance of serum hepatitis B virus ribonucleic acid. Hepatobiliary
of hepatitis C virus infection: new estimates of age-specific antibody to Surg Nutr 2015;4:197–202.
HCV seroprevalence. Hepatology 2013;57:1333–42. [23] European Association For The Study Of The Liver.EASL clinical practice
[4] Trepo C, Chan HL, Lok A. Hepatitis B virus infection. Lancet guidelines: management of chronic hepatitis B virus infection. J Hepatol
2014;384:2053–63. 2012;57:167–85.
[5] Seo SI, Choi HS, Choi BY, et al. Coexistence of hepatitis B surface antigen [24] World Health Organization. Guidelines for the prevention care and
and antibody hepatitis B surface may increase the risk of hepatollular treatment of persons with chronic hepatitis B infection: Mar-15. World
carcinoma in chronic hepatitis B virus infection:a retrospective cohort Health Organization, 2015.
study. J Med Virol 2014;86:124–30. [25] Satin SK, Kumar M, Lau GK, et al. Asian-Pacific clinical practice
[6] Liu W, Hu T, Wang X, et al. Coexistence of hepatitis B surface antigen guidelines on the management of hepatitis B: a 2015 update. Hepatol Int
and anti-HBs in Chinese chronic hepatitis B virus patients relating to 2016;10:1–98.
gentype C and mutations in the S and P gene reverse transcriptase region. [26] Terrault NA, Bzowej NH, Chang KM, et al. AASLD guidelines for
Arch Virol 2012;157:621–34. treatment of chronic hepatitis B. Hepatology 2016;63:261–83.
[7] Zhang JM, Xu Y, Wang XY, et al. Coexistence of hepatitis B surface [27] Kock J, Theilmann L, Galle P, et al. Hepatitis B virus nucleic acids
antigen (HBsAg) and heterologous subtype-specific antibodies to HBsAg associated with human peripheral blood mononuclear cells do not
among patients with chronic hepatitis B virus infection. Clin Infect Dis originate from replicating virus. Hepatology 1996;23:405–13.
2007;44:1161–9. [28] Van Bommel F, Barrens A, Mysiekova A, et al. Serum hepatitis B virus
[8] Chen YL, Mo YQ, Zheng DH, et al. Patients with coexistence of RNA levels as an early predictor of hepatitis B envelope antigen
circulating hepatitis B surface antigen and its antibody may have a strong seroconversion during treatment with polymerase inhibitors. Hepatol-
predisposition to virus reactivation during immunosuppressive therapy: ogy 2015;6l:66–76.
a hypothesis. Med Sci Monit 2017;23:5980. [29] Van Campenhout MJH, van Bömmel F, Pfefferkorn M, et al. Host and
[9] Kwak MS, Chung GE, Yang JI, et al. Long-term outcomes of HBsAg/ viral factors associated with serum hepatitis B virus RNA levels among
anti-HBs double-positive versus HBsAg single-positive patients with patients in need for treatment. Hepatology 2018;68:839–47.
chronic hepatitis B. Sci Rep 2019;9:1–7. [30] Li Y, He L, Li Y, et al. Characterization of serum HBV RNA in
[10] Chinese Society of Hepatology and Chinese Society of Infectious patients with untreated HBeAg-positive and-negative chronic hepatitis
DiseasesGuidelines of prevention and treatment for chronic hepatitis B B infection. Hepatitis Monthly 2018;18: doi: 10.5812/hepatmon.
(2015). Chin J Hepatol 2015;7:1–18. 62079.
[11] Fung J, Lai CL, Seto WK, et al. Nucleoside nucleotide analogues in the [31] Farag MS, van Campenhout MJH, Pfefferkorn M, et al. Hepatitis
treatment of chronic hepatitis B. J Antimicrob Chemother 2011;66:2715–25. B virus RNA as early predictor for response to pegylated interferon alpha
[12] Lucifora J, Xia Y, Reisinger F, et al. Specific and nonhepatotoxic degradation in HBeAg-negative chronic hepatitis B. Clin Infect Dis 2021;72:202–11.
of nuclear hepatitis B virus cccDNA. Science 2014;343:1221–8. [32] Jiang B, Liu C, Su R, et al. Value of serum HBV RNA in HBeAg-negative
[13] Wang J, Xu ZW, Liu S, et al. Dual gRNAs guided CRISPR/Cas9 system patients with chronic hepatitis B. Zhonghua gan zang bing za zhi
inhibits hepatitis B virus replication. World J Gastroenterol 2015;21:9554. 2019;27:668–72.