Actually, the question is quite simple. Strictly speaking, patients with chronic liver disease (including those with slow hepatitis B) need treatment if they meet the following conditions: 1. they have problems in their liver; 2. these problems can be solved by doctors applying current scientific treatments; Junsheng Gu, Department of Infectious Diseases, First Affiliated Hospital of Zhengzhou University; 3. there is a significant difference in their outcome with or without treatment. However, this issue is also complex. Why again? Because sometimes not all problems in the patient’s liver can be diagnosed very simply! To explain: Let’s start with the simple ones. It is well known that if a patient with liver disease has abnormal liver function, that is to say elevated transaminases, then he definitely needs treatment. This is because the most common method used by hepatologists today to determine if a patient has a liver problem is to see if their transaminases are elevated. Generally speaking, elevated transaminases indicate inflammation of the liver, which can lead to edema and degeneration of liver cells in mild cases and necrosis in severe cases. If transaminases continue to rise, that is, if hepatitis continues, degeneration and necrosis of liver cells will continue to occur, followed by serious consequences such as fibrosis of the liver and cirrhosis of the liver. Therefore, patients with elevated aminotransferases should generally be treated promptly. Then again, it is complicated. We often come across patients who are told that they do not need treatment because their transaminases are normal. In fact, most of these patients really do not need treatment. This is because relevant studies have shown that most patients with liver disease with normal transaminases do not have inflammation in their livers. Liver inflammation is the direct cause of almost all adverse liver outcomes. That means that if there is no inflammation in the liver there is no need for treatment. So this (i.e., no treatment) is true for most patients with slow hepatitis B who have normal liver function. But the problem is – and this is sometimes a fatal mistake if you analyze the problem this way – is that for one thing, a normal serum transaminase does not mean that all patients with liver disease do not have inflammation in their liver. A scientific study has often been done to illustrate the problem: many liver biopsies from chronic hepatitis patients with normal transaminases were put under the microscope and it was found that a significant proportion of them had inflammation in their livers, and after a long period of observation, it was found that some of these chronic liver disease patients with normal liver function and inflammation in their livers on liver biopsy, if left untreated for a long time The probability of developing cirrhosis (or progressive liver disease) is significantly higher in these patients with normal liver function and inflammation in the liver biopsy. This means that the standard of normal transaminases of less than 40 U/L is sometimes unreliable! Therefore some experts in the US believe that this criterion should be revised from scratch! But a standard revision is not an easy task, and all of us are still using this seemingly normal standard today, but in fact it may really be outdated. Second, because liver function tests only represent the transaminase level at the point in time when a person’s blood is drawn (and transaminases can sometimes change dramatically within a few days), a doctor cannot determine, based on liver function test results, what transaminase changes have occurred in the past or may occur at any time in the future. Therefore, for some patients with chronic liver disease who have normal liver function, treatment is not only needed, but very much needed, sometimes urgently needed. The most common example or lesson learned from such cases encountered in clinical work is that some patients have normal liver function every time they come to the hospital for recheck and have been observed without medication, and some years later, their liver is bad and their face is black (medically called liver disease face), and once the ultrasound is checked, the liver disease has progressed, and if it is already cirrhosis or liver cancer, then there is some delay in the matter. Finally, to sum up this group of patients in one sentence, I think they would be a group like this – they have normal liver function, but there is evidence that their liver disease has recently progressed significantly or definitively (this group of patients is in need of treatment)! And the strongest of this evidence is, first, liver histopathology, followed by ultrasound, etc. (imaging tests such as ultrasound can reflect the cumulative damage to the patient’s liver over time). The last thing that many people find difficult to understand in clinical work is that many patients do not understand the problem: the patient is a chronic hepatitis B, liver function is normal, the virus is positive (that is, HBVDNA can be detected). Many patients ask this after you prescribe them, “Doctor, will the medicine you prescribed for me kill the hepatitis B virus in my body?” This is actually a good question, because if I were a patient, I would probably ask the same question at the beginning of my medical visit. — So I’ll explain the question below. (This question can be summarized as: Do patients with chronic hepatitis B who have normal liver function and are positive for hepatitis B virus need antiviral therapy?) (Please note that I am talking about “antiviral therapy” here, while in the previous question I said “treatment”, they are two different concepts.) Antiviral therapy for patients with hepatitis B is a very complex and critical issue, especially the first antiviral therapy for patients (which affects all subsequent treatments). This treatment cannot be stopped as often as you wish. On the contrary, the timing of antiviral treatment for patients with chronic hepatitis B is important. If the timing is not ripe, the effect of antiviral treatment will not be very good, just as the firing of porcelain is about the fire. And this medical so-called timing refers to the transaminase elevation, and generally speaking, the higher the transaminase, the better the effect of antiviral treatment will be. So, most of the time, anti-hepatitis B virus therapy is only indicated for patients with elevated transaminases. So, if the patient’s transaminases are not high, that is, if the liver function is normal, do they need antiviral therapy or not? First: If the patient has normal liver function and no progression of liver disease, I think it can be left untreated and certainly no antiviral therapy is needed. Because although the hepatitis B virus is positive, but the patient’s liver function is normal and liver disease is not progressing, if you give treatment, the patient has no benefit other than spending money. Second: If the patient has normal liver function but the liver disease is progressing slowly, he can be given liver-protective treatment and regular review, and if the disease can be controlled, antiviral treatment may not be given. Thirdly, if there is evidence that the liver disease is progressing rapidly despite normal liver function, and if liver-protective therapy alone is not effective after observation, anti-hepatitis B virus treatment should be given promptly. Only antiviral treatment can eliminate liver inflammation and control the progression of the disease at the root.