We read with great surprise the article by Kim et al1 reporting high risks of hepatocellular carcinoma (HCC) and death in patients with untreated chronic hepatitis B who were classified by them as patients in 'immune-tolerant' (IT) phase. This conclusion contradicts to the general belief that there is little or no disease progression during the IT phase of chronic HBV infection, as best demonstrated in a 5-year histological follow-up study.2 Some issues of serious concern on this study, especially their IT phase patients, require clarification and further discussion to minimise misleading messages.
IT phase of perinatally acquired chronic HBV infection is typically seen in Asian children or young adults with high HBV DNA, normal alanine aminotransferase (ALT), hepatitis B e-antigen (HBeAg) seropositivity and normal or minimal liver histological changes. After age of 20–25 years, IT phase may gradually convert to immune clearance or immune active (IA) phase, which is characterised...
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