Objective <p>The relationship between changes in hepatitis B surface antibody (HBsAb) levels and hepatic adverse events after hepatitis B surface antigen (HBsAg) clearance remains unclear. This study aimed to investigate the correlation between HBsAb level changes and hepatic adverse events in non-cirrhotic patients following HBsAg clearance.</p> Methods <p>We retrospectively analyzed patients with HBsAg seroclearance achieved via pegylated interferon-alpha (Peg-IFNα) therapy in the Department of Hepatology II at Beijing Ditan Hospital, Capital Medical University, from October 2008 to December 2023. Participants were stratified by baseline HBsAb levels into negative (&lt; 10 mIU/mL), low (10–100 mIU/mL), medium (100–1000 mIU/mL), and high (≥ 1000 mIU/mL) groups. Based on HBsAb trends during follow-up, patients were categorized into declining, stable, and rising groups. The primary endpoint was the incidence of hepatic adverse events after HBsAg clearance.</p> Results <p>A total of 390 patients were included, with a median age of 38 (32–44) years and a median follow-up of 53.50 (11.00–173.00) months. During follow-up, 4 cases of hepatic adverse events occurred, all in the declining group (4 cases, 3.05%), while none were observed in the stable or rising groups (<i>P</i> = 0.018). Changes in HBsAb levels were inversely correlated with the incidence of hepatic adverse events (<i>rs</i> = -0.125, <i>P</i> = 0.014).</p> Conclusion <p>Declining HBsAb levels after HBsAg clearance may be associated with an increased risk of hepatic adverse events.</p> Clinical trial <p>This study was registered at ClinicalTrials.gov (ID: NCT04301908; registration date: 03/06/2020; <a href="https://register.clinicaltrials.gov/">https://register.clinicaltrials.gov/</a>).</p>