Patients with inactive chronic hepatitis B virus (HBV) infection are assumed to be free from liver disease. Accordingly, antiviral drug treatment is not recommended for these patients. However, the extent of liver damage in these patients has not been evaluated fully. The aim of this study was to evaluate the extent of liver damage in patients with inactive HBV. Liver biopsy was conducted in 141 inactive HBV carriers [HBeAg-negative, low levels of HBV DNA (<= 10,000 copies/ml) and normal levels of serum alanine aminotransferase (ALT)]. The extent of hepatic inflammation and fibrosis was evaluated in these patients by examining liver biopsy specimens. Although the patients were inactive HBV carriers, mild to moderate levels of necroinflammation (HAI necroinflammation score HAI-N1 >= 7) were detected in 36 of 141 (26%) patients. Seventeen patients had a severe degree of hepatic fibrosis (HAI fibrosis score HAI-F >= 3). A total of 10 patients had both considerable necroinflannmation (HAI-N1 >= 7) and severe fibrosis (HAI-F >= 3). All 10 patients with significant hepatic inflammation and fibrosis were male and older than 25 years. However, all were HBeAg-negative and expressed low levels of HBV DNA and normal ALT levels. The study demonstrates that features of liver damage were present in a considerable number of the patients. Assessment of liver biopsy specimens in a larger cohort of inactive HBV carriers is necessary to establish management guidelines for such patients. J. Med. Virol. 82: 1350-1354, 2010. (C) 2010 Wiley-Liss, Inc.