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高正常ALT慢性乙型肝炎患者应否启动抗病毒治疗
DOI: 10.3969/j.issn.1001-5256.2023.08.001
利益冲突声明：本文不存在任何利益冲突。
作者贡献声明：李欣洁负责查阅文献，撰写文搞；沈弢审阅文稿；庄辉审审阅文稿并最后定稿。
Should antiviral treatment be initiated for chronic hepatitis B patients with high-normal alanine aminotransferase?
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摘要: 现行指南建议对ALT升高和HBV DNA阳性慢性乙型肝炎(CHB)患者给予抗病毒治疗。但越来越多的研究表明，血清高正常ALT(0.5~1倍正常值上限)慢性HBV感染者的肝组织可见显著坏死炎症和/或纤维化，并存在进展性肝病如肝硬化、肝细胞癌、乙型肝炎相关并发症甚至死亡的风险。本文讨论了血清高正常ALT的定义、血清高正常ALT慢性乙型肝炎患者的临床和病毒学特点，以及对此类患者应否启动抗病毒治疗。Abstract: Current guidelines recommend antiviral treatment for chronic hepatitis B (CHB) patients with elevated alanine aminotransferase (ALT) and positive HBV DNA. However, more and more studies have shown that CHB patients with high-normal ALT 0.5 to 1 times the upper limit of normal have significant necroinflammation and/or fibrosis in the liver and the risk of progressive liver diseases such as liver cirrhosis, hepatocellular carcinoma, hepatitis B-related complications, and even death. This article discusses the definition of high-normal ALT and the clinical and virological features of CHB patients with high-normal ALT, as well as whether antiviral treatment should be initiated for such patients.
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Key words:
- Hepatitis B, Chronic /
- Alanine Transaminase /
- Therapeutics
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表 1 各国CHB指南、共识或专家意见推荐的ALT ULN
Table 1. ALT upper limits of normal recommended by CHB guidelines, consensus statements, or expert opinions from various countries
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表 2 2015年APASL指南关于血清低正常和高正常ALT的定义
Table 2. Definitions of low-normal and high-normal ALT in APASL guidelines in 2015
ALT水平 定义 低正常 ≤0.5×ULN 高正常 ＞0.5×ULN~1×ULN 轻度升高 ＞1×ULN~2×ULN 升高 ＞2×ULN
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表 3 其他研究关于低正常和高正常ALT的定义
Table 3. Definitions of low-normal and high-normal ALT in other studies
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表 4 低正常和高正常ALT CHB患者肝组织病理学比较
Table 4. Comparison of liver histopathology between chronic HBV infected patients with low-normal and those with high-normal ALT
作者 显著纤维化 显著炎症 低正常ALT者 高正常ALT者 P值 低正常ALT者 高正常ALT者 P值 Lai[17] 5%(1/20) 25%(10/39) 0.03 20%(4/20) 41%(16/39) 0.002 Gui1)[18] 16.6%(26/157) 40%(28/95) ＜0.001 Liao[24] 17.4%(4/23) 40.6%(13/32) NS2) 0(0/23) 15.6%(5/32) NS2) Li1)[25] 19.8%(20/101) 36.4%(106/291) 0.002 Duan[19] 41.7%(55/132) 61.0%(119/195) 0.001 26.5%(35/132) 44.6%(87/195) 0.001 注：1)肝组织学显著病变，2)无显著差异。
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