Background and Aims: Chronic hepatitis B is the main cause of liver cancer. However, the most neglected group has been treatment-naive chronic hepatitis B patients with normal alanine aminotransferase (ALT). People have tended to subjectively assume that the liver lesions of these pa-tients are not serious and do not need antiviral treatment. However, the truth is not as optimistic as we thought. We aimed in this study to analyze the proportion of significant inflammation or fibrosis in aforementioned patients. Meth-ods: Medline, Embase, and Cochrane Library were searched up to January 10th 2020, to identify studies of these pa-tients with liver biopsy. The double arcsine method was used with a random-effect model to combine the proportion of significant inflammation or fibrosis. Potential heterogene-ity was explored by subgroup analysis and meta-regression. Outcome of interests included the proportion of significant inflammation or fibrosis and cirrhosis. The secondary out-come was to find the risk factors of significant histologi-cal changes. Results: Nineteen eligible studies, with 2,771 participants, were included. The pooled proportion of sig-nificant inflammation or fibrosis was 35％ [95％ confidence interval (CI): 27 to 43] and 30％ (95％ CI: 25 to 36), re-spectively. The pooled proportion of cirrhosis was 3％ [95％ CI: 1 to 5, (12 studies; 1,755 participants)]. In subgroup analysis, old age [vs. young (<40 years-old), 44％ vs. 26％, p=0.012] was significantly associated with higher fibrosis stage as well as cirrhosis [vs. young (<40 years-old), 4.8％ vs. 1.8％, p<0.001]. Conclusions: About 1/3 of the treat-ment-naive chronic hepatitis B patients with normal ALT show significant histological changes, and some even have cirrhosis.