BACKGROUND AND AIMS: Hepatitis B virus (HBV) infection is a major global health problem which progresses to liver cirrhosis (LC) and hepatocellular carcinoma (HCC). Early prediction of disease changes and intervention are essential to slow disease progression and protect liver function. This study aimed to analyze the clinical characteristics of patients with HBV-related LC and HCC at different serum alanine aminotransferase (ALT) levels and explore the risk factors of HBV infection progressing to LC/HCC. METHODS: A total of 379 patients with HBV infection treated in The Third People's Hospital of Shenzhen between January 2014 and December 2016 without any antiviral drug therapy were enrolled. Patients were divided into the LC/HCC and non-LC/HCC groups based on clinical diagnosis, which was determined through imaging and expressions of pathological and laboratory test markers, and patients with LC/HCC were further divided into three groups according to the serum ALT levels. Differences in general information, clinical symptoms, and expression levels of serological indices of the above groups were compared and analyzed, logistic regression was used to analyze the risk factors for LC/HCC development, and the clinical diagnostic efficacy of indicators was judged by the receiver operator characteristic (ROC). RESULTS: LC/HCC mainly occurred in the ALT normal and mildly elevated groups, with 70.83% of patients with HCC having an LC background. In the comparison of different ALT level groups, the moderately-severely elevated group had the highest proportion of patients with skin jaundice, abdominal varices, rebound tenderness, higher white blood cell and neutrophil (NEUT) counts; and higher levels of aspartate aminotransferase, glutamyl transpeptidase, total bilirubin, and direct bilirubin. The LC/HCC group was older and had significantly higher proportions of male patients, alcohol consumption, and combined hypertension than the non-LC/HCC group (all  < 0.05). Logistic regression analysis showed that age, combined hypertension, abdominal varicose veins, subcostal palpation, and NEUT count were risk factors for LC/HCC development; and the area under the curve for this model on the ROC analysis was 0.935 (95% confidence interval 0.899-0.972) with specificity and sensitivity of 97.4% and 70.7%, respectively. CONCLUSIONS: Advanced age, combined hypertension, abdominal varicose veins, subcostal palpation, and high NEUT count are risk factors for LC/HCC development in patients with untreated HBV infection.