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We read with great interest the recent publication by Kim et al 1 showing that patients with untreated immune tolerant (IT) chronic hepatitis B with normal alanine aminotransferase (ALT) levels had significantly higher risks of hepatocellular carcinoma (HCC) and death/transplantation than treated immune active (IA) patients who had elevated ALT levels. These results indicate that ALT is not a sensitive surrogate marker for liver cell damage, and the IT phase of HBV infection cannot be considered fully benign.2 Chu and Liaw3 have challenged this view because they speculated that the IT group in that study might include IA patients who were in remission state after experiencing unrecognised minimal ALT elevations. Apparently, the highly dynamic nature of ALT perturbation makes it inadequate to act as a predictor for HCC.
We have developed and validated an easy-to-use scoring system for primary liver cancer (PLC) risk prediction. The development data set was set up in 1996 based on a community-based prospective cohort (qidong hepatitis B infection cohort (QBC)) established in Qidong, China.4 It contained …
Contributors CF screened the raw data, performed the statistical analysis and drafted the preliminary manuscript. ML and YG did HBV DNA tests and screened the raw data. TC, YS and JW maintained the derivation cohort. JC and JianhL maintained the validation cohort. YJ was responsible for frozen plasma samples. JianqL and GQ assisted in the acquisition of data. HT, JC and JG were responsible for the study concept and design, the acquisition, analysis and interpretation of data, critical revision of the manuscript for important intellectual content, and obtaining funding.
Funding This study was supported by the National Key Projects Specialized in Infectious Diseases (2017ZX10201201-008-003, 2017ZX10201201-006-002, 2012ZX10002-008-002 and 2012ZX10002-008-003), National Key Research Projects for Precision Medicine (2017YFC0908103), National Natural Science Foundation of China (81572312) and the Research Funding for Young Medical Talents of Nantong Municipal Commission of Health and Family Planning (WQZ2015007).
Competing interests None declared.
Patient consent Obtained.
Ethics approval The ethical committee of Qidong People’s Hospital/Qidong Liver Cancer Institute approved the study after a plenary session.
Provenance and peer review Not commissioned; internally peer reviewed.