On-treatment alanine aminotransferase flares are associated with better clinical outcomes in children with chronic hepatitis B

Alanine aminotransferase (ALT) flares are primarily considered immune-mediated events that may indicate remission of disease or clearance of infection. However, the impact of ALT flares on clinical treatment outcomes in pediatric patients with chronic hepatitis B (CHB) remains unknown. This study sought to investigate the possible correlations between ALT flares and treatment outcomes in pediatric CHB patients. This retrospective cohort study involved 611 pediatric patients with CHB. ALT flares were defined as a substantial increase in ALT levels, surpassing 10 times the upper limit of normal. Patients were categorized into three groups according to the occurrence and timing of ALT flares: no flare, baseline ALT flares, and on-treatment ALT flares. Among 611 participants enrolled, 491 were in the no flare group, 51 in the baseline ALT flare group, and 69 in the on-treatment ALT flare group. During a median follow-up duration of 20 months, 44.7% (273/611) achieved HBsAg loss, 55.9% (314/561) achieved HBeAg clearance, and 86.2% (507/589) achieved undetectable HBV DNA levels. Multivariate Cox regression analysis indicated that on-treatment ALT flares were positively correlated with higher probabilities of HBsAg loss (HR = 1.70, 95% CI: 1.26-2.48) and HBeAg clearance (HR = 1.84, 95% CI: 1.12-2.12). A substantial proportion of pediatric CHB patients receiving antiviral therapy achieved favorable treatment outcomes. On-treatment ALT flares emerged as a promising predictor of favorable treatment responses, particularly HBsAg loss and HBeAg clearance.