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We aimed to assess liver histological changes of HBeAg-negative chronic hepatitis B (CH patients with normal ALT, and determined the association between significant liver injury and age, ALT, and HBV DNA levels. We retrospectively examined 327 patients who underwent liver biopsy from 2009 to 2018. Significant liver histological change is defined as liver necroinflammation ≥ G2 and/or liver fibrosis ≥ F2. The proportion of patients with significant liver necroinflammation or fibrosis in the high-normal ALT group (ALT 20 U/L) was