Chronic Hepatitis B and Steatotic Liver Disease: From Bidirectional Interaction to Hepatocellular Carcinoma Risk

Chronic hepatitis B (CHB) and steatotic liver disease (SLD) are among the most prevalent chronic liver diseases worldwide and increasingly coexist, particularly in regions where hepatitis B virus (HBV) infection remains endemic. Reported prevalence of hepatic steatosis in CHB varies widely, reflecting the diagnostic modality and population studied rather than a single underlying figure. Across series using liver biopsy, ultrasound or controlled attenuation parameter (CAP), hepatic steatosis in CHB is associated more consistently with host metabolic and genetic factors than with markers of viral replication. Hepatic steatosis is repeatedly associated with lower serum HBV DNA, lower quantitative hepatitis B surface antigen (HBsAg), lower hepatitis B envelope antigen (HBeAg) positivity and a higher probability of HBsAg seroclearance. These virological associations do not consistently predict long-term liver outcomes, and hepatocellular carcinoma (HCC) risk persists after HBsAg seroclearance. Studies using hepatic steatosis as the exposure report inconsistent findings for HCC, with adjusted estimates ranging from inverse to strongly positive. Metabolic dysfunction shows a more consistent association with HCC, particularly diabetes, obesity and multiple concurrent cardiometabolic risk factors, and this association persists in virologically suppressed patients and after HBsAg seroclearance. Hepatic steatosis, metabolic dysfunction, steatohepatitis and fibrosis should therefore be assessed as distinct prognostic variables rather than as a single entity, with implications for HCC risk stratification and surveillance in CHB.