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Pretreatment alanine transaminase level may not be the most important predictor of HBeAg loss in the older patient


Jung Il Lee, MD, Department of Internal Medicine, Division of Gastroenterology, Inha University College of Medicine, 7-206, 3rd ST, Sinheung-Dong, Jung-Gu, Incheon, 400-711, Korea
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Background: Elevated pretreatment alanine aminotransferase (ALT) over two times the upper limit of normal reference range has been accepted as a marker for predicting HBeAg loss and an indicator for initiating antiviral therapy. Recently, several opinions argued that in patients aged over 40 years, the treatment should be started if they have elevated serum hepatitis B virus (HBV) DNA without elevated ALT. However, initiating treatment in these patients might be argued against by the concept that the rate of HBeAg loss depends on the pretreatment ALT.

Aim: This study was conducted to investigate the usefulness of pretreatment ALT in predicting HBeAg loss in patients aged over 40 years under lamivudine treatment.

Methods: We retrospectively analyzed 820 HBeAg-positive patients treated with lamivudine. The patients with hepatocellular carcinoma at or after initiating the lamivudine treatment and patients with evident liver cirrhosis were excluded. Three hundred fifty-five patients met the criteria and were divided into two groups: ≤40 years of age (Group 1) and >40 years of age (Group 2).

Results: Analysis using the Kaplan–Meier method and the log rank test showed that the cumulative rate of HBeAg loss was not different in the two groups. Multivariate modelling indicated that an elevated pretreatment ALT level was a predictor of HBeAg loss in Group 1 (P<0.05), whereas it failed to act as a predictor in Group 2.

Conclusion: Antiviral therapy might not need to be deferred until the ALT level increases in order to enhance the chance of HbeAg loss in HBV DNA-(+) patients aged over 40 years.