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We read with interest the paper by Yuen et al (Gut 2005;54:1610–4). This study included a large patient cohort with chronic hepatitis B and analysed the determinants predicting outcome. The authors concluded that low level viraemia and mildly elevated serum alanine aminotransferase (ALT) levels more commonly led to the development of complications. This conclusion however was not supported by their findings as the independent predictive factors were male sex, age, stigmata of chronic liver disease, and others, whereas serum ALT and hepatitis B virus (HBV) DNA levels were not.
It is questionable if patients with mildly elevated baseline ALT levels are truly associated with a higher risk of complications. As shown in fig 2 of their paper, the incidence of complications in the group with ALT >2–6× upper limit of normal (ULN) and the group with ALT >6×ULN was still significantly higher compared with the group with ALT <0.5×ULN that had the lowest risk of complications. More importantly, serum ALT level was not an independent risk factor predicting poor outcome in the Cox multivariate analysis, suggesting lower serum ALT and/or HBV DNA levels were only …
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