These findings underscore HDV’s distinct and additive role in accelerating liver fibrosis, beyond the effect of HBV alone, consistent with prior evidence that chronic HDV infection accelerates progression to cirrhosis and hepatocellular carcinoma [6, 22], which may be explained by HDV-driven synergistic activation of HBV X (HBx)-mediated TGF-β and c-Jun signaling cascades, promoting hepatic fibrogenesis [23, 24]. This evidence concerns the gene TGFB1 and hepatocellular carcinoma.