Hepatitis B virus exposure and metabolic dysfunction-associated steatotic liver disease in U.S. adults: A nationally representative analysis from NHANES 2017-2020.

BACKGROUND

The association between hepatitis B virus (HBV) exposure (anti-HBc+) and metabolic dysfunction-associated steatotic liver disease (MASLD) constitutes a critical public health dilemma. Emerging evidence reveals paradoxical epidemiological patterns, with observational studies demonstrating lower NAFLD/MAFLD prevalence among individuals with HBV exposure despite its hepatotropic nature-contradicting conventional pathophysiological frameworks. Under the 2023 AASLD criteria requiring concurrent cardiometabolic risk factors with hepatic steatosis for MASLD diagnosis, understanding HBV-MASLD interactions across diverse populations becomes imperative. Current evidence predominantly derives from Asian cohorts, leaving U.S. population-level associations underexplored.

OBJECTIVE

To investigate the population-level HBV-MASLD association among U.S. adults using nationally representative data.

METHODS

We analyzed 2017-2020 NHANES data (n=6,342 adults, representing 181.71 million residents) through complex survey-weighted analyses. MASLD required hepatic steatosis (controlled attenuation parameter ≥285 dB/m) plus ≥1 CMRF. HBV exposure was diagnosed as HBcAb (+). Weighted multivariable logistic regression adjusted for demographic and metabolic confounders (R 4.2.2 and FreeStatistics v1.9.2; two-tailed α=0.05).

RESULTS

The retrospective cross-sectional study (mean age 51.1±17.4 years; 52.5% female) included 509 HBV-exposed individuals (8.03%) and 1,712 MASLD cases (26.99%). HBV-exposed individuals demonstrated: 1) lower MASLD prevalence (21.6% vs. 27.5%); 2) persistently inverse association after full adjustment (OR 0.57, 95% CI 0.40-0.81); 3) consistent patterns across subgroups without significant interactions by demographics (all P > 0.05). Sensitivity analyses in the complete-case subset (n=5,355) confirmed robustness (OR 0.58, 95% CI 0.40-0.85).

CONCLUSIONS

This observational U.S. study identifies an inverse association between HBV exposure and MASLD, suggesting the need for further investigation into metabolic assessment in this population.