Predictors of survival in chronic hepatitis B infection are surprisingly not well described. Various studies have identified different factors that were associated with adverse outcomes. For example, Niederau and colleagues,¹ in a cohort of European patients, identified lack of clearance of hepatitis B e antigen (HBeAg) as a predictor of decreased survival. Others have identified older age, presence of cirrhosis, and the persistence of alanine aminotransferase (ALT) elevations as adverse prognostic signs in an antibody to hepatitis B e antigen (anti-HBe) positive cohort.² In patients undergoing a flare of hepatitis B activity, whether spontaneous or chemotherapy induced, the presence of jaundice is an ominous sign.³ None of these adverse predictive factors are unexpected. Clearly, jaundice, cirrhosis, older age, and elevated ALT are obvious adverse predictive factors but until recently we have not had the tools to predict, years in advance, the outcome of chronic hepatitis B infection. This is important because we would prefer to offer treatment only to those who are likely to develop complications of the disease, and not to those whose disease will become inactive without long term sequelae. Recently, new predictors of outcome have been identified. At last year’s American Association for Study of Liver Disease (AASLD) meeting and the recent European Association for Study of the Liver (EASL) meeting, new data were presented that contribute to this debate. In addition, the article by Yuen and colleagues⁴ in this issue of Gut also forces us to re-examine some of our assumptions about hepatitis B prognosis and therefore treatment (see page 1610).

To some extent our current management algorithms …