Most 'immune tolerant' hepatitis B patients turn immune active within five years; adenoma count and size both sharpen colonoscopy risk

The edition in brief

In the RADICAL consortium cohort, 951 strictly defined immune-tolerant patients with chronic hepatitis B (median age 33, median follow-up 13 years) transitioned to immune-active disease (ALT of 50 U/L or more) in 51% by 5 years, 67% by 10 years and 72% by 15 years; a high-normal ALT (20 to 30 U/L, then above 30) carried a higher risk (subdistribution HR 1.74 and 3.13). Progression to significant fibrosis (6.3%) and hepatocellular carcinoma (1.1%) at 15 years was low. In 16,870 adults with repeat colonoscopies, five-year advanced neoplasia incidence rose with the number of non-advanced adenomas: 1.3% with none, 4.0% with 1 to 2, 5.3% with 3 to 4 and 10.1% with 5 to 10, and was higher with at least one small (6 to 9 mm) than diminutive-only adenomas. A meta-analysis of three randomised trials (274 patients) found no significant difference in adverse events between elafibranor and placebo in primary biliary cholangitis (any adverse event RR 1.06), but most safety outcomes were underpowered. In the LiveSMART trial of 230 adults with cirrhosis and portal hypertension, lactulose lowered injurious falls (3.5% vs 8.5%) and a sequential lactulose then tele-delivered tai chi approach improved a composite outcome (win ratio 2.7).