This difference was small and likely not clinically important. In fact, the proportion of patients with an ALT level >40 U/L in both groups at baseline and during follow-up was similar. The findings of the current study support the literature that suggests dual-infected patients

often have a disease course characterized by dominance of one virus over the other Erlotinib (i.e., either HBV over HCV or HCV over HBV).19, 24, 28-30 In contrast to other studies, the dual-infected patients in the current study did not have increased rates of advanced liver disease or HCC compared with their HBV-monoinfected counterparts.8-10, 23, 29, 30, 31-33 In fact, a recent systematic review and meta-analysis suggested that HBV/HCV dual infection is not an increased risk for HCC compared with HBV or HCV monoinfection.34

However, our median follow-up for each group was only 38 months for the HBV-monoinfected patients and 33 months for the HBV/HCV dual-infected patients, making any comparisons between groups with respect to end-stage liver disease and HCC either premature or beyond the scope of this study. This study is not without its limitations. There is evidence that genotype distribution, and as a corollary, country of origin may predict natural history and clinical outcome anti-PD-1 antibody inhibitor of HBV-monoinfected patients.35-38 Unfortunately, HBV and HCV genotype and mutation data, as well as histological data, were only MCE available in a minority of our

patients, limiting our observations in this regard. Furthermore, we compared patients with HBV/HCV dual infection with patients with HBV monoinfection but not HCV monoinfection. The study design was based in part on the relative lack of comparative studies of dual infection with HBV monoinfection. The 15-year period of study may introduce some variability in the data interpretation based on the number of hepatologists and gastroenterologists involved in the care of these patients and the different generations of HBV DNA and HCV RNA assays used over this time interval. Although it is likely that different types of molecular tests with varying sensitivities were used over the course of the study period, it is unlikely these methodological differences would have led to significant variation in levels of viremia in most cases. The viral dominance pattern in the vast majority (≈80%) of study cases was fairly clear in which one virus was completely undetectable and was therefore less likely to be affected by variations produced by such factors. Finally, the number of non-Asian patients in the case group was few, and subsequently so was their ethnicity-matched control group (≈20% of the study population). Nevertheless, they were among the consecutive patients who met our inclusion and exclusion criteria during the specified study period.