https://orcid.org/0000-0002-0763-0334
Abstract
Introduction
Hepatitis B virus (HBV) is a significant cause of chronic hepatitis, leading to liver complications such as cirrhosis and hepatocellular carcinoma. Toll-like receptors (TLRs) are critical in the immune response to HBV. This study investigates the TLR3 1377 C/T polymorphism’s association with clinical outcomes in chronic hepatitis B patients.
Materials and methods
A case-control study included 136 participants (66 cases and 70 controls). The patients were categorized as having chronic active or inactive hepatitis B based on serological, biochemical, and molecular parameters. TLR3 1377 C/T polymorphism was analyzed using PCR-RFLP. The correlation between TLR3 genotypes, HBeAg status, liver enzyme levels (ALT and AST), and symptomatic presentation was assessed.
Results
Among the 66 cases, the CC genotype was more frequent in males with chronic active hepatitis (14 males, 5 females), but no significant gender-based difference was observed in genotype distribution. A significant association was found between the CC genotype and symptomatic presentation in chronic active cases (P = 0.015). However, no significant association was detected between TLR3 genotypes and HBeAg status (P > 0.05). Elevated ALT and AST levels were more prevalent in chronic active cases.
Conclusions
The TLR3 1377 C/T polymorphism, particularly the CC genotype, may influence the clinical presentation of chronic hepatitis B, particularly in symptomatic cases. However, its impact on HBeAg status and overall chronicity appears limited. Further studies are needed to clarify the role of TLR3 polymorphisms in HBV pathogenesis and their potential as therapeutic targets.
Figures
Citation: Awadelkarim KE, Osman NAM, Eleragi AMS, Nail AMA, Abuzeid N, Elangeeb ME, et al. (2025) Chronic active and chronic inactive hepatitis B virus infection: Comparative study of genetic polymorphism and blood profile measures. PLoS One 20(4): e0322268. https://doi.org/10.1371/journal.pone.0322268
Editor: Benjamin M. Liu, Children's National Hospital, George Washington University, UNITED STATES OF AMERICA
Received: January 9, 2025; Accepted: March 19, 2025; Published: April 29, 2025
Copyright: © 2025 Awadelkarim et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: Data Availability: Data underlying the study cannot be made publicly available due to ethical restrictions imposed by the ethical committee of Omdurman Islamic University. Data would be available upon justified request after approval of this committee. The data request may be sent to Professor Abdelsamee Elobied Mohamed Elamin, Dean of Faculty and Head of Research Committee, a.elsamee@oiu.edu.sd.
Funding: The authors express gratitude and appreciation to the Faculty of Medical Laboratory Sciences at Omdurman Islamic University Sudan and UBCOM/University of Bisha, SA, for their assistance and support. The work was supported by the University of Bisha's Deanship of Graduate Studies and Scientific Research through the Fast-Track Research Support Program, for which we are grateful.
Competing interests: The authors have declared that no competing interests exist.
Introduction
The hepatitis B virus (HBV) is a well-known agent of acute and chronic hepatitis [1]. The progression and outcome of chronic hepatitis B virus (HBV) infection are intricately linked to the immune response and the interaction between the virus and the host immune system [2,3]. Viral hepatitis is a necro-inflammatory liver disease of variable severity. The connection between cirrhosis, hepatocellular carcinoma (HCC), chronic liver disease, and persistent HBV infection was well documented. Patients with these conditions have an increased risk of complications and account for a considerable number of deaths each year [4].
Chronic HBV infection has different phases, with the HBeAg-negative phase leading to virologic and clinical outcomes like HBeAg-negative chronic infection and hepatitis, cirrhosis, HCC, and severe liver injury. However, these phases of chronic HBV infection are characterized based on serological and biochemical parameters, but these phases are not necessarily sequential [5–7]. HBe Ag (+) chronic infection is characterized by high serum viral DNA, HBeAg (+) status, normal or low serum ALT, mild or no liver necroinflammation, with no or slow progression of fibrosis. HBeAg (+) chronic hepatitis is characterized initially by widely oscillating serum HBV DNA and ALT levels, ultimately decreasing from high to low or undetectable DNA and from high to normal ALT (<30 IU/mL for men and <19 IU/mL for women) [8–12]. The ALT variation represents acute changes in inflammation or intermittent episodes of hepatitis, eventually leading to loss of HBeAg in wild-type infection. Liver histology ranges from high to minimal necroinflammation, and core and pre-core mutations emerge [13,14].
The absence of HBeAg and the presence of anti-HBe, undetectable or low amounts of HBV DNA (<2000 IU/mL) in PCR-based tests, normal ALT levels, and little to no necroinflammation are characteristics of the inactive HBsAg carrier state, sometimes referred to as immunological control. Strong host immune response during this phase results in low or undetectable viremia and minimal liver damage, as shown by consistently normal necroinflammation markers [7,15]. Usually, the HBV DNA load should be below 2000 IU/ml [16]. HBeAg (-) chronic hepatitis is characterized by persistent necroinflammation, in which attempts at immune clearance are ineffective, HBV DNA levels are moderate to high, and liver disease is progressive [13]. Toll-like receptors (TLRs) are the most important family of pattern recognition receptors (PRRs) and play a critical role in both innate and adaptive immunity [17–19]. It is known that TLR 2, 3, 4, 7, 8, and 9 have a role in the pathogenesis of several viral infections, including hepatitis B and C [20]. Genetic polymorphisms such as single nucleotide polymorphisms (SNPs) in the TLR3 gene are significant factors in susceptibility to viral infections like HBV and can impact the clinical outcomes of infected individuals. These TLR3 variants may modify treatment outcomes and disease progression and influence the host immune response to viral infections, such as HBV [21–23]. The current study examined the allelic variation of TLR 3 (rs 3775290) concerning various clinical outcomes of sixty-six patients with chronic hepatitis B infection to ascertain its correlation with chronicity condition.
Materials and methods
The study was designed as a cross-sectional hospital-based study [24]. Sixty-six (66) chronically HB-infected individuals were included. The ethical approval was received from the Omdurman Islamic University ethical review board (NO: OIU/FMLS/DO/C17 on 12/12/2020). The study complies with all regulations, and written informed consent was obtained from all participants before the blood sample was withdrawn.
Data collection
Besides data collected from clinical records, self, and non-self-administrated questionnaires were used to gather sociodemographic data.
Sampling and serological testing
Blood specimens were collected from the participants in the period from September 7, 2021, to March 15, 2022: a lithium heparin container for serology and an EDTA container for molecular analysis. Commercial ELISA kit Fortress (Fortress Diagnostic-United Kingdom) was used to detect HBsAg according to the manufacturer’s instructions.
The electrochemiluminescence immunoassay “ECLIA” detects HBeAg on cobas e 411 immunoassay analyzers. Serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST), using routine clinical test kits according to the manufacturer’s instructions (Human Diagnostics, Germany) [25].
Molecular analysis
The guanidine chloride procedure, described by Montgomery and Sise in 1990, was used to extract the viral DNA. The presence of HBV genomes was determined using nested and multiplex PCR with HBV genotype-specific primers. (1). A real-time PCR protocol was carried out to determine viral load. A viral DNA load of less than 2000 IU/mL was considered a chronic inactive CHB, and a viral load of more than 2000 IU/mL was considered a chronic active CHB. For the detection of TLR 3 (1377 C/T) genetic polymorphism, PCR-RFLP) was used as described by Noguchi et al. [26]. The PCR fragment carrying 1337CT SNP was amplified using the following prime pair: F: -5’ CCAGGCATAAAAAGCAATATG-3’ and R: -5’ GGACCA GGCAAAGGAGTTC-3’ e. The fragments were separated by agarose gel (3%) electrophoresis, 275 bp+62 bp RFLP products for the CC genotype, 337 bp+275 bp+62 bp products for the CT genotype, and 337 bp RFLP products for the TT genotype were obtained for 1337CT.
Results
The distribution of cases by gender and chronic activity status was examined. Among the 50 cases of chronic active disease, 17 (34%) were females, and 33 (66%) were males. Of the 16 cases of chronic inactive disease, 5 (31%) were females, and 11 (68%) were males. Overall, out of 66 total cases, 33.3% were females (22 cases), and 66.7% were males (44 cases). There was no significant difference between the gender distributions across the illness activity status (P = 1) (Table 1).
Table 2 showed that among chronic active cases, 17 (94.4%) were HBeAg positive, which is significantly higher than the 1 (5.6%) in chronic inactive cases (p = 0.04). The symptomatic presentation did not differ considerably between chronic active and inactive cases, with 50% being symptomatic in both groups (p = 0.245). Overall, 18/66 (27.3%) of all cases were HBeAg positive, and 4/66 (6.1%) were symptomatic.
The liver enzymes ALT and AST levels in patients with chronic active and chronic inactive cases are shown in Table 3. Normal ALT levels of 39 (78%) and AST levels of 35 (70%) were detected among chronically active patients versus 11 (22%) abnormal ALT and 15 (30%) abnormal AST levels. Just 6.2% and 6.3% of chronic inactive cases exhibited abnormal ALT and AST levels, respectively, compared to 93.8% and 93.7% of normal cases. All 66 cases were accounted for in ALT and AST measurements (Table 3).
Table 4 compares ALT abnormalities between HBeAg-positive and HBeAg-negative individuals. Among HBeAg-positive patients (n=18), 33.3% (6) showed abnormal ALT levels versus 66.7% (12) with normal levels. In HBeAg-negative individuals (n=48), only 12.5% (6) had abnormal ALT, while 87.5% (42) were normal. Overall, 18.2% (12/66) of the cohort exhibited ALT abnormalities, with no statistically significant difference between groups (p=0.073), though a marginal trend was observed.
Table 5 revealed that out of 18 HBeAg+ve, AST normal and abnormal levels were 10 (55,6%) and 8 (44.4%), respectively. In contrast, within HBeAg-ve, 40 (83.3%) detected normal AST levels, and 8 (16,7%) showed increased AST levels with significant difference (P-value 0.026) of AST levels across HBeAg status.
Table 5 showed a statistically significant association between HBeAg status and AST abnormalities in individuals with chronic hepatitis B (p = 0.026). AST abnormalities were more prevalent in HBeAg-positive individuals (8; 44.4%) compared to HBeAg-negative individuals (8; 16.7%). This suggests that HBeAg-positive status is associated with higher levels of liver inflammation, likely due to ongoing active viral replication. In contrast, most HBeAg-negative individuals had normal AST levels (40; 83.3%), aligning with the natural progression of chronic hepatitis B, where HBeAg loss is often linked to reduced viral activity and hepatic inflammation.
Table 6 shows the distribution of male and female TLR3 SNP 1337 CT genotypes (CC, CT, and TT) among those with chronic active and chronic inactive infection. The CC genotype was found in 14 men and five females with chronic active infection and four males and three females with chronic inactive infection (P-value = 0.635). The CT genotype was associated with 15 men and 10 females with chronic active infection and six males and 0 females with chronic inactive infection (P-value = 0.141). At a p-value of 0.524, There were four males and two females with a chronic active infection for the TT genotype and 1 male and two females with a chronic inactive infection (P-value of 0.524). There were 50 chronic active and 16 chronic inactive cases (P-value = 1.000) based on the following: 33 males and 17 females had a chronic active infection. In contrast, 11 males and five females had a chronic inactive infection.
Table 7 presents the distribution of TLR3 SNP 1337CT genotypes among chronic active and chronic inactive hepatitis B patients, categorized by HBeAg status (positive or negative). There was no significant association with HBeAg status for the CC genotype between chronic active and chronic inactive patients (P = 0.629). Similarly, for the CT genotype, the association was not statistically significant (P = 0.141). The TT genotype also showed no significant association (P = 1.000). When combining all genotypes, the difference in HBeAg status between chronic active and chronic inactive patients reached statistical significance (P = 0.05).
Table 8 shows the distribution of TLR3 SNP 1337CT genotypes among symptomatic and asymptomatic patients with chronic active and chronic inactive hepatitis B. For the CC genotype, a significant association with symptom status was observed in chronically active patients (P = 0.015), with symptomatic patients having a higher frequency of the CC genotype. The CT genotype did not significantly correlate with symptom status (P = 0.618) or the TT genotype (P = 0.453). When considering the overall genotypic distribution, the difference in symptom status was not statistically significant (P = 0.215).
Discussion
The clinical and epidemiological features of individuals with chronic hepatitis B are investigated in this case-control study, with particular attention paid to the distribution of genders, HBeAg status, liver enzyme levels, and TLR3 SNP 1337 CT genotypes in the Sudanese population. Nucleotide polymorphisms, even one, can impact disease susceptibility, drug sensitivity, development of personalized treatment strategies, and determining new therapeutic targets. Recent studies have emphasized the relationship between genetic polymorphisms and specific diseases [27]. The primary goal is to find correlations between these variables and the disease’s chronic activity status. The study aims to enhance our understanding of how the disease progresses and provide guidance for better chronic hepatitis B management strategies by examining these characteristics. The complex process by which HBV infection progresses to liver cirrhosis and HCC is impacted by several variables, including immune, environmental, viral, and demographic factors. To manage and forecast outcomes for patients with liver illnesses connected to HBV, it is essential to comprehend the molecular pathways and discover biomarkers for prognosis assessment [28,29].
In this study, the gender distribution of chronic active and chronic inactive hepatitis B cases showed no significant difference, with males forming a higher proportion (66% in chronic active and 68% in chronic inactive). This was supported by previous studies on the gender gap in instances of chronic hepatitis B and the higher incidence of hepatitis B in men. This result suggests that gender does not influence the progression from chronic inactive to active hepatitis B, suggesting other factors like viral load and host immune response may be more critical [30–32].
HBeAg, a marker of active viral replication, was significantly higher in chronic active cases (94.4%) than in chronic inactive cases (5.6%), with a P-value of 0.04. This finding aligns with existing literature that associates HBeAg positivity with active viral replication and liver inflammation. It also emphasizes the role of HBeAg as a marker of active viral replication and its association with disease activity status [33,34]. Symptomatic presentation did not differ significantly between the two groups, with 50% of patients being symptomatic (P = 0.245). Regular monitoring of HBeAg and other markers is crucial for managing hepatitis B patients, as symptom presence alone may not accurately indicate disease activity status.
Moreover, studying the abnormal ALT and AST levels in this study showed that in the case of ALT, HBeAg-positive chronic hepatitis B is linked to higher HBV DNA levels and fluctuating ALT, indicating liver inflammation. The study found more ALT abnormalities in HBeAg-positive (33.3%) than HBeAg-negative (12.5%) individuals, consistent with the literature, but statistical significance was lacking (p = 0.073), suggesting other influencing factors. HBeAg-negative status generally correlates with lower viral replication and inflammation, though some patients may develop HBeAg-negative chronic hepatitis with persistent ALT elevation and fibrosis [10,35–38].
Furthermore, our findings indicate a significant association between HBeAg status and AST abnormalities (p = 0.026), with HBeAg-positive individuals showing a higher prevalence of AST abnormalities (44.4%) than HBeAg-negative individuals (16.7%). This supports the findings that suggest HBeAg positivity is linked to higher HBV DNA levels and increased hepatic inflammation due to active viral replication (European Association for the Study of the Liver, 2022; Terrault et al., 2021). While HBeAg-negative individuals generally exhibit lower inflammatory activity, some may develop HBeAg-negative chronic hepatitis, leading to persistent AST elevations, which agrees with the findings of Papatheodoridis et al., 2021. These findings highlight the importance of liver enzyme monitoring in chronic hepatitis B management [10, 35–38].
The analysis of TLR3 SNP 1337 CT genotypes in this investigation did not reveal a significant association with chronic activity status, HBeAg status, or symptom presentation. Our findings indicate that TLR3 SNP 1337 CT genotypes may not be significant determinants of disease progression or symptomatology in our cohort. The lack of significant genotype association with HBeAg status (P = 0.05) and symptom presentation (P = 0.215) further supports this conclusion, suggesting that other genetic or environmental factors may play more prominent roles in influencing these outcomes. However, these results supported previous reports that illuminated the intricate interactions between immune responses and genetic determinants by elucidating the genetic variants of TLR3 and their possible influence on disease progression and symptomatology in the setting of hepatitis B infection [39,40]. However, we assumed that the 1377C/T polymorphism (rs3775290) of TLR 3 might be associated with HBV infection in Sudanese patients, where our study shows a significant difference in P value (0.05) when we compare TLR3 SNP 1337CT polymorphism genotypes (CC, CT, TT) harboring serological marker HBeAg, with chronic active and chronic inactive.
It is worth saying that this study’s strength is its comprehensive analysis of various factors, including gender, HBeAg status, liver enzyme levels, and TLR3 SNP 1337 CT genotypes concerning chronic hepatitis B activity. This broad approach offers an in-depth understanding of the etiology and course of the disease. Furthermore, employing precise clinical and laboratory parameters improves the dependability of the results.
However, the study’s small sample size, cross-sectional design, and lack of detailed information on influencing factors may limit generalizability and causal relationships, necessitating future investigations with larger sample sizes, longitudinal designs, and more comprehensive data collection.
Considering the clinical implications and future directions, the findings of this study emphasize the importance of regularly monitoring HBeAg status and liver enzyme levels in managing chronic hepatitis B. While gender and TLR3 SNP 1337 CT genotypes do not significantly influence disease activity or symptom presentation, the strong association between HBeAg positivity and chronic active disease highlights its value as a key marker in clinical practice. Future research should continue to explore additional genetic factors and their interactions with environmental influences better to understand the complex mechanisms underlying hepatitis B progression.
In conclusion, the study highlights the link between HBeAg positivity and chronic active disease in chronic hepatitis B patients, emphasizing the need for continuous research and comprehensive monitoring to improve disease management and outcomes.
References
- 1. Naito H, Hayashi S, Abe K. Rapid and specific genotyping system for hepatitis B virus corresponding to six major genotypes by PCR using type-specific primers. J Clin Microbiol. 2001;39(1):362–4. pmid:11136801
- 2. Dey D, Pal S, Chakraborty BC, Baidya A, Bhadra S, Ghosh R, et al. Multifaceted defects in monocytes in different phases of chronic hepatitis B virus infection: lack of restoration after antiviral therapy. Microbiol Spectr. 2022;10(6):e0193922. pmid:36445121
- 3. Liu C, Shih Y-F, Liu C-J. Immunopathogenesis of acute flare of chronic hepatitis B: with emphasis on the role of cytokines and chemokines. Int J Mol Sci. 2022;23(3):1407. pmid:35163330
- 4. Roca Suarez AA, Testoni B, Baumert TF, Lupberger J. Nucleic acid-induced signaling in chronic viral liver disease. Front Immunol. 2021;11:624034. pmid:33613561
- 5. Chu CM. Natural history of chronic hepatitis B virus infection in adults with emphasis on the occurrence of cirrhosis and hepatocellular carcinoma. J Gastroenterol Hepatol. 2000;15 Suppl:E25-30. pmid:10921378
- 6. Zhang Y-Y. New strategy treating hepatitis B virus (HBV) infection: a review of HBV infection biology. Adv Treat Hepatitis C and B. 2017:373-94.
- 7. Pollicino T, Caminiti G. HBV-integration studies in the clinic: role in the natural history of infection. Viruses. 2021;13(3):368. pmid:33652619
- 8. Liu J, Yu Y, Zhao H, Guo L, Yang W, Yan Y, et al. Latest insights into the epidemiology, characteristics, and therapeutic strategies of chronic hepatitis B patients in indeterminate phase. Eur J Med Res. 2024;29(1):343. pmid:38902822
- 9. Li Y, Zhu Y, Gao D, Pan Y, Wang J, Zhang S, et al. HBeAg-positive CHB patients with indeterminate phase associated with a high risk of significant fibrosis. Virol J. 2024;21(1):287. pmid:39538258
- 10. Papatheodoridis GV, Chan HL-Y, Hansen BE, Janssen HLA, Lampertico P. Risk of hepatocellular carcinoma in chronic hepatitis B: assessment and modification with current antiviral therapy. J Hepatol. 2015;62(4):956–67. pmid:25595883
- 11. Liu B, Li N, Wang R, Li X, Li Z, Marion T. Key roles for phosphorylation and the coiled-coil domain in TRIM56-mediated positive regulation of TLR3-TRIF-dependent innate immunity. J Biol Chem. 2024;300(5):107249.
- 12. Shen Y, Li N, Wang J, Liu B, Lester S, Li K. TRIM56 is an essential component of the TLR3 antiviral signaling pathway. J Biol Chem. 2012;287(43):36404–13.
- 13. Gish RG, Given BD, Lai C-L, Locarnini SA, Lau JYN, Lewis DL, et al. Chronic hepatitis B: Virology, natural history, current management and a glimpse at future opportunities. Antiviral Res. 2015;121:47–58. pmid:26092643
- 14. Lakshmanan K, Liu BM. Impact of point-of-care testing on diagnosis, treatment, and surveillance of vaccine-preventable viral infections. Diagnostics (Basel). 2025;15(2):123. pmid:39857007
- 15. Tsukune Y, Sasaki M, Komatsu N. Reactivation of hepatitis B virus in patients with multiple myeloma. Cancers (Basel). 2019;11(11):1819. pmid:31752356
- 16. Papatheodoridis GV, Manolakopoulos S, Liaw Y-F, Lok A. Follow-up and indications for liver biopsy in HBeAg-negative chronic hepatitis B virus infection with persistently normal ALT: a systematic review. J Hepatol. 2012;57(1):196–202. pmid:22450396
- 17. Shi W, Zhang Z, Ling C, Zheng W, Zhu C, Carr MJ, et al. Hepatitis B virus subgenotyping: history, effects of recombination, misclassifications, and corrections. Infect Genet Evol. 2013;16:355–61. pmid:23538336
- 18. Iwasaki A, Medzhitov R. Control of adaptive immunity by the innate immune system. Nat Immunol. 2015;16(4):343–53. pmid:25789684
- 19. Kawai T, Akira S. The role of pattern-recognition receptors in innate immunity: update on Toll-like receptors. Nat Immunol. 2010;11(5):373–84. pmid:20404851
- 20. Kondo Y, Ueno Y, Shimosegawa T. Toll-like receptors signaling contributes to immunopathogenesis of HBV infection. Gastroenterol Res Pract. 2011;2011:810939. pmid:22190911
- 21. Medzhitov R, Preston-Hurlburt P, Janeway CA Jr. A human homologue of the Drosophila toll protein signals activation of adaptive immunity. Nature. 1997;388(6640):394–7. pmid:9237759
- 22. Du Y, Wu J, Liu J, Zheng X, Yang D, Lu M. Toll-like receptor-mediated innate immunity orchestrates adaptive immune responses in HBV infection. Front Immunol. 2022;13:965018. pmid:35967443
- 23. Tuncel B, Kaygusuz S, Sayın Kocakap DB, Aksoy E, Azkur AK. Do CCR5 (CCR5Δ32) and TLR3 (RS5743313) gene polymorphisms prevent chronic hepatitis B infection?. J Med Virol. 2023;95(1):e28376. pmid:36478230
- 24. Rezigalla AA. Observational study designs: synopsis for selecting an appropriate study design. Cureus. 2020;12(1):e6692. pmid:31988824
- 25. Bergmeyer H. IFCC methods for the measurement of catalytic concentrations of enzymes. part 3, IFCC. Method for alanine aminotransferase (l-alanine 2 -oxoglutarate aminotransferase, ec 2.6.1.2). Clin Chim Acta. 1980;105(1):145F-72F. pmid:7398084
- 26. Noguchi E, Nishimura F, Fukai H, Kim J, Ichikawa K, Shibasaki M, et al. An association study of asthma and total serum immunoglobin E levels for Toll-like receptor polymorphisms in a Japanese population. Clin Exp Allergy. 2004;34(2):177–83. pmid:14987294
- 27. Zazuli Z, Duin NJCB, Jansen K, Vijverberg SJH, Maitland-van der Zee AH, Masereeuw R. The impact of genetic polymorphisms in organic cation transporters on renal drug disposition. Int J Mol Sci. 2020;21(18):6627. pmid:32927790
- 28. Kanda T, Goto T, Hirotsu Y, Moriyama M, Omata M. Molecular mechanisms driving progression of liver cirrhosis towards hepatocellular carcinoma in chronic hepatitis B and C infections: a review. Int J Mol Sci. 2019;20(6):1358. pmid:30889843
- 29. Riazalhosseini B, Mohamed R, Devi Apalasamy Y, Mohamed Z. Association of deleted in liver cancer-1 gene polymorphism with increased risk of chronicity of disease among Malaysian patients with hepatitis B infection. Pharmacogenet Genomics. 2021;31(9):185–90. pmid:34320605
- 30. Dimzova M, Kondova-Topuzovska I, Milenkovic Z, Gaseva M, Chaloska-Ivanova V, Serafimoski V, et al. Clinical significance of quantitative HBs antigen in the prediction of liver fibrosis in patients with chronic hepatitis B. Pril (Makedon Akad Nauk Umet Odd Med Nauki). 2018;39(1):51–8. pmid:30110270
- 31. Wang W-T, Zhao X-Q, Li G-P, Chen Y-Z, Wang L, Han M-F, et al. Immune response pattern varies with the natural history of chronic hepatitis B. World J Gastroenterol. 2019;25(16):1950–63. pmid:31086463
- 32.
Fattovich G, editor. Natural history and prognosis of hepatitis B. Seminars in liver disease. 333 Seventh Avenue, New ….: Copyright© 2002 by Thieme Medical Publishers, Inc.; 2003
- 33. Cooper SL, King WC, Mogul DB, Ghany MG, Schwarz KB, Hepatitis B Research Network (HBRN). Clinical significance of quantitative e antigen in a cohort of hepatitis B virus-infected children and adults in North America. J Viral Hepat. 2021;28(7):1042–56. pmid:33893706
- 34. Lin S-R, Yang T-Y, Peng C-Y, Lin Y-Y, Dai C-Y, Wang H-Y, et al. Whole genome deep sequencing analysis of viral quasispecies diversity and evolution in HBeAg seroconverters. JHEP Rep. 2021;3(3):100254. pmid:33870157
- 35. Lampertico P, Agarwal K, Berg T, Buti M, Janssen HL, Papatheodoridis G, et al. EASL 2017 clinical practice guidelines on the management of hepatitis B virus infection. J Hepatol. 2017;67(2):370-98.
- 36. Liaw Y-F. Natural history of chronic hepatitis B virus infection and long-term outcome under treatment. Liver Int. 2009;29 (Suppl 1):100–7. pmid:19207972
- 37. Terrault NA, Lok ASF, McMahon BJ, Chang K-M, Hwang JP, Jonas MM, et al. Update on prevention, diagnosis, and treatment of chronic hepatitis B: AASLD 2018 hepatitis B guidance. Hepatology. 2018;67(4):1560–99. pmid:29405329
- 38. Zhang H, Zhang M, Zhang Q, Yu Y, Zhang F, Wang J, et al. Visualizing in situ viral replication across the natural history of chronic HBV infection. Hepatol Commun. 2023;7(4):e0111. pmid:36995994
- 39. Al-Qahtani A, Al-Ahdal M, Abdo A, Sanai F, Al-Anazi M, Khalaf N, et al. Toll-like receptor 3 polymorphism and its association with hepatitis B virus infection in Saudi Arabian patients. J Med Virol. 2012;84(9):1353–9. pmid:22825813
- 40. Soumbara T, Bonnet C, Hamed CT, Veten F, Hemeyine M, Fall-Malick F-Z, et al. Genetic variation of TLR3 gene is associated with the outcome of hepatitis b infection in mauritanian patients: case control study. BMC Infect Dis. 2024;24(1):616. pmid:38907187
