For hepatitis B virus (HBV) e‐antigen (HBeAg)‐positive chronic hepatitis B (CHB) patients, HBeAg seroconversion is a prerequisite for a definite course of antiviral treatment. 1 Unfortunately, for both entecavir (ETV) and tenofovir disoproxil fumarate (TDF), HBeAg clearance or seroconversion only occurs in a minority of patients even after multiple years of antiviral therapy. The gut microbiota appears to play a critical role in age‐related immune clearance of HBV. 2 Several studies have indicated that CHB patients with liver cirrhosis have different microbiota compared to healthy people. 3 , 4 The “leakage hypothesis” has linked gut microbiota to the onset and progression of liver diseases. 5 Thus, we reported on a case‐controlled, open‐label pilot trial of fecal microbiota transplantation (FMT) for CHB patients.

Methods and Results

In the present study, 18 eligible patients who remained persistently positive for HBeAg following >3 years of ongoing ETV‐ or TDF‐based antiviral therapy were enrolled (Table 1). Among them, 5 participants were enrolled in the FMT arm whereas 13 were enrolled in the control arm according to whether they accepted FMT or not. All participants in both arms continued with their previous antiviral treatment such as ETV. After obtaining written informed consents, FMT treatment was performed by gastroscope for the participants in the FMT arm every 4 weeks until HBeAg clearance was achieved. Four of 5 patients in the trial arm received one to seven FMT treatments, and 1 participant exited the trial after five FMT treatments. The FMT treatment schedule and donor information for each patient are outlined in Supporting Fig. S1A. Gut microbiota profiling was performed for all donors and patients in the FMT arm, which indicated there was a significant change in the microbiota composition compared to that at the baseline (Fig. 1A). Principal components analysis showed that the gut microbiota profile of the donors was distinct from that of the participants in the FMT arm at baseline (Supporting Fig. S1B).

Table 1. Baseline Demographic and Clinical Characteristics of the Enrolled Patients Characteristic FMT Arm Control Arm P Value Age, years, median (range) 27 (24‐42) 33 (19‐68) 0.3736 Male sex, no. (%) 5 (100) 13 (100) 1.0000 HBV DNA <500 IU/mL, no. (%) 5 (100) 9 (69.2) 0.2778 HBsAg titer (IU/mL), median (range) 533 (96‐3,874) 580 (5‐3,747) 0.8490 HBeAg titer (S/CO), median (range) 4.6 (1.8‐32.3) 3.4 (1.7‐21.4) 0.2571 HBeAg‐positive, no. (%)a 5 (100) 13 (100) 1.0000 HBeAb‐positive, no. (%)b 0 (0) 0 (0) 1.0000 ALT <1 × ULN, no. (%)c 4 (80) 12 (92) 0.4902 AST <1 × ULN, no. (%)c 5 (100) 13 (100) 1.0000 Presence of cirrhosis, no. (%)d 0 (0) 0 (0) 1.0000 Previous use of interferon, no. (%) 2 (40) 3 (23) 0.5827 Duration of antiviral treatment before enrollment (months), median (range) 43 (29‐54) 40 (31‐124) 0.6090

Figure 1 Open in figure viewer PowerPoint (A) Gut microbiota profiling of the donors used and the participants in the FMT arm at baseline and after FMT. Donor: the donors used in the trial. (B), (C), (D), (E), (F), and (G) refer to donor B, C, D, E, F, and G, respectively. Gut microbiota profiling for donor A is not shown because it was not successfully performed. PA, PB, PC, PD, and PE refer to patient A, B, C, D, and E, respectively. 0, baseline; 1, after the first FMT; 2, after the second FMT; 3, after the third FMT; 4, after the fourth FMT. Legends describe the bacterial genus. (B) Compared to that at the baseline, significant decline in HBeAg titer is observed than that in the control arm at the end of follow‐up (P = 0.0002, Mann‐Whitney U test). (C) Occurrence of HBeAg clearance in two arms (P = 0.0001, Mantel‐Cox's test). Abbreviation: S/CO, signal‐to‐cutoff ratio.

At the end of follow‐up, a significant decline in HBeAg titer rather than hepatitis B surface antigen (HBsAg) titer was observed in the FMT arm compared to that at the baseline (Fig. 1B and Supporting Fig. S1C). Moreover, HBeAg titer declined gradually after each round of FMT (Supporting Fig. S1D). In the FMT arm, 2 participants (patients C and E) achieved HBeAg clearance after one FMT whereas patient D achieved HBeAg clearance after two FMT treatments. In contrast to that, none of the control patients achieved HBeAg clearance (0 of 13) at the conclusion of the study (P = 0.0001, Mantel‐Cox's test; Fig. 1C). Alanine aminotransferase (ALT) and HBV DNA were also detected at 4 weeks after each round of FMT and remained under the lower limit of detection (data not shown). No HBeAg seroconversion was observed at the end of follow‐up. No significant adverse events, such as abdominal discomfort, diarrhea, or constipation, were reported in the patients that received FMT. Further information is shown in the Supporting Information.