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Is antibody to surface antigen associated with hepatitis B reactivation in patients with resolved hepatitis B?

In an issue of HEPATOLOGY, Paul et al. reported an interesting meta-analysis study that showed that the presence of antibodies to hepatitis B surface antigen (HBsAg, anti-HBs) is associated with a decreased risk of hepatitis B virus reactivation (HBVr) in patients with resolved hepatitis B undergoing chemotherapy. However, in this meta-analysis, some points should be further clarified. First, the definition of HBVr for resolved hepatitis B was not consistent in previous reports and included criteria such as HBsAg reverse seroconversion, a detectable HBV viral load from a previously undetectable status, elevation of the HBV viral load to 2,000 IU/ mL, or a 10-fold in increase in HBV DNA. In our previous randomized controlled trial (RCT), an elevation of HBV viral load to 2,000 IU/mL was adopted as the threshold of HBVr. However, Paul et al. incorrectly classified the HBVr definition of our RCT as detectable HBV DNA. In our RCT, the baseline HBV DNA levels of the seven cases of HBVr in the control arm ranged from undetectable (<12 IU/mL) to 61 IU/mL. This indicated that all the patients had more than a 10-fold increase in HBV viral load during HBVr, instead of only detectable HBV DNA. Second, the incidence of HBVr (HBV DNA elevation) is higher than that of HBsAg reverse seroconversion during rituximab treatment, even in the presence of anti-HBs (Fig. 1). Based on our RCT, 4 patients positive for anti-HBs (with titers ranging from 21 to> 1,000 mIU/mL) had HBVr in the control arm. The patient with the highest titer of anti-HBs (>1,000 mIU/mL) developed HBVr with an increase in the HBV viral load to 46,300 IU/mL. Another study also showed a high risk of HBVr (21%) in anti-HBs-positive patients undergoing rituximab treatment. The information provided by this metaanalysis seems to have overlooked the risk of HBVr in anti-HBs-positive lymphoma patients undergoing rituximab-based chemotherapy. Third, the incidence of reactivation depends on the criteria of HBVr. In our RCT, the difference between the incidence of HBVr and HBsAg reverse seroconversion was 7.4% (17.9% versus 10.3%). The risk and odds ratio of HBVr in this meta-analysis might be distorted by mixing all types of HBVr definitions together. The data should be precisely presented by grouping the enrolled studies according to their definition of HBVr.