Chronic hepatitis B (CHB) can lead to cirrhosis, hepatocellular carcinoma, and premature death. Elevated alanine aminotransferase (ALT) levels ≥ the upper limit of the standardized upper limit (ULN) are a major determinant in evaluating for antiviral therapy; however, ALT levels alone may not be predictive of liver fibrosis. However, there is no conclusive evidence on how fibrotic the liver of patients with chronic hepatitis B is when their ALT is normal. Researchers from Stanford University conducted a systematic review and meta-analysis of this. The study suggests that about one in five patients with chronic hepatitis B who have an ALT ≤ 40 IU/L may have significant liver fibrosis. The findings will be published in the February 2014 issue of Aliment Pharmacol Ther. The primary objective of the study was to determine the proportion of patients with chronic hepatitis B who have an ALT ≤ 40 IU/L and a liver fibrosis stage ≥ 2. Secondary objectives included subgroup analyses based on the following indicators. These metrics were available to hepatitis B researchers who searched the literature included in EMBASE and MEDLINE (January 1990-June 2012). The search formula was “Hepatitis B” [subject term] OR “Hepatitis B virus” [subject term] OR “Hepatitis B, chronic” [subject term] )AND “alanine aminotransferase” [subject line] ). Abstracts from recent conferences on gastroenterology and liver organization in the United States were also searched, and those containing the term “hepatitis” were also included in the study. A total of nine studies were included in this meta-analysis (n = 830 cases). The proportion of patients with chronic hepatitis B who developed significant fibrosis when their ALT level was ≤ 40 IU/L was 20.7%. This percentage was independent of the following factors. HBeAg status, high HBV DNA levels, race, or age, although this proportion may be higher in patients over 30-40 years of age. Even using the new ULN criteria (30 IU/L (men) and 19 IU/L (women)), the proportion was 27.8%. The findings suggest that about one-fifth of patients with chronic hepatitis B with ALT ≤ 40 IU / L may have significant liver fibrosis. The results suggest that physicians should individualize the treatment of such patients, which requires further evaluation of the condition and treatment. e antigen (HBeAg) status, high hepatitis B virus (HBV) DNA levels, Asian ethnicity, low ULN ≤ 30 IU / L (men) and 19 IU / L (women) and advanced age.