Most 'immune tolerant' hepatitis B patients became immune active within five years, and lactulose cut falls in cirrhosis

The edition in brief

In 951 strictly defined immune tolerant patients with chronic hepatitis B from an international consortium, median age 33 and median follow-up 13 years, the probability of moving to immune active disease (ALT 50 U/L or more) was 51% by 5 years, 67% by 10 years and 72% by 15 years; a high-normal ALT predicted transition (subdistribution HR 1.74 for 20 to 30 U/L and 3.13 above 30 U/L). Significant fibrosis (6.3%) and hepatocellular carcinoma (1.1%) were uncommon by 15 years. The authors suggest closer monitoring or pre-emptive therapy for high-normal ALT. A 230-patient randomised trial in cirrhosis with portal hypertension found lactulose, followed by remote tai chi, reduced injurious falls (4% vs 12%) and non-injurious falls (19% vs 32%), with a win ratio of 2.7 (95% CI 1.3 to 5.5) for the hierarchical composite. A meta-analysis of three trials (274 patients) found no significant safety differences between elafibranor and placebo in primary biliary cholangitis (any adverse event RR 1.06, 0.97 to 1.16), with most outcomes underpowered. A two-centre randomised trial of 158 patients found no difference in delayed gastric emptying between side-to-side and end-to-side gastrojejunostomy after pancreatoduodenectomy (38.0% vs 30.4%, RR 1.25, 0.81 to 1.94). A review estimates that chronic liver disease affects over 1.5 billion people. The pearl covers six-monthly liver cancer surveillance.