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Chronic hepatitis B: course and prognosis
Last reviewed: 04.07.2025
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There are more than 300 million HBV carriers worldwide. Therefore, in most patients the disease should be mild and only in some cases can it progress.
The clinical course varies considerably. Many patients remain in a stable, compensated state. This is especially typical in asymptomatic cases when histological examination of the liver reveals a picture of a mild form of chronic hepatitis.
Clinical deterioration in an initially stable HBV carrier may be explained in several ways. The patient may convert from a replicative to an integrated state. This is usually accompanied by remission, which may be permanent, with a decrease in serum enzyme activity to normal values and improvement in liver histology; such a transformation may be observed in 10-20% of cases each year.
The prognosis of chronic hepatitis B depends on the severity of the liver disease, which is usually milder in women. Unfavorable factors include age over 40 years and ascites. Apparently, there are geographic and age-related features in the course of the disease. In Italian children with a positive test for HBV DNA, the probability of transition to an anti-HBe-positive and HBV-DNA-negative state with normalization of serum transaminase activity in childhood is 70%; while the probability of HBsAg disappearance is 29%. On the contrary, on average, within 4.0±2.3 years, HBsAg disappears in only 2% of healthy carriers or patients with chronic hepatitis, of Chinese origin. In HBeAg-negative patients over 40 years old with developed liver cirrhosis, HBsAg disappears more often.
In a study conducted by Italian physicians, 20% of adult patients with chronic hepatitis developed active cirrhosis within 1-13 years. Older age, the presence of bridging necrosis on liver biopsy, persistence of serum HBV DNA, and HDV superinfection indicate a poor prognosis.
In general, the prognosis for healthy HBV carriers is good. A 16-year follow-up of asymptomatic HBV carriers in Montreal showed that they remained asymptomatic and had a low risk of death from HBV-related cirrhosis or hepatocellular carcinoma. The rate of HBsAg loss was 0.7% per year. The prognosis of Italian HBsAg carriers with normal serum transaminase activity is also good.
A study of long-term mortality among those infected during the 1942 hepatitis B epidemic in the US Army showed a slightly higher incidence of hepatocellular carcinoma. Mortality from nonalcoholic chronic liver disease was lower. Few healthy adult men became carriers of HBV.
HBV infection of the transplanted liver is common in patients with HBV infection, especially with positive tests for HBV DNA and HBeAg. Retransplantation for recurrent hepatitis B is contraindicated due to high mortality. However, it is possible in HBV-positive patients in whom graft failure has a different genesis.
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