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免疫耐受期HBV感染者抗病毒治疗的临床争议

胡林慧 王艳

引用本文:
Citation:

免疫耐受期HBV感染者抗病毒治疗的临床争议

DOI: 10.12449/JCH240505
利益冲突声明:本文不存在任何利益冲突。
作者贡献声明:胡慧林负责文章撰写;王艳负责结构框架设计并最后定稿。
详细信息
    通信作者:

    王艳, wangyanwang@bjmu.edu.cn (ORCID: 0000-0002-8577-0527)

Clinical controversies over antiviral therapy for patients in the immune-tolerant phase of hepatitis B virus infection

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  • 摘要: 为实现“2030年消除病毒性肝炎作为公共卫生危害”的目标,目前针对慢性HBV感染提倡更广泛筛查、更积极预防和抗病毒治疗。但“慢性HBV感染免疫耐受期患者是否启动抗病毒治疗”尚无统一观点。部分专家认为免疫耐受期患者肝脏免疫微环境稳定,疾病进展可能小,且治疗效果不佳,不建议启动抗病毒治疗;而另有多项研究提示免疫耐受期患者肝脏仍存在炎症损伤,有疾病进展风险,接受抗病毒治疗后成本效益高,因此部分专家建议对免疫耐受期患者应积极启动抗病毒治疗。本文对慢性HBV感染者免疫耐受期的定义、抗病毒治疗的利弊进行文献综述,并基于既往文献进行初步的系统分析,以增加对慢性HBV感染免疫耐受期是否抗病毒治疗的证据积累,为未来免疫耐受期患者的规范临床诊疗奠定基础。

     

  • 表  1  不同国家指南CHB患者IT期的标准

    Table  1.   Diagnostic criteria of IT in different guidelines of AASLD, EASL, APASL, JSG and CMA

    地区 IT期定义
    HBsAg HBeAg HBV DNA(IU/mL) ALT(U/L) 组织病理
    美国肝病学会(AASLD)2 + + >106 男性<35 女性<25 无炎症坏死或纤维化
    欧洲肝病学会(EASL)3 + + >107 男女均<40 无炎症坏死或纤维化
    亚太肝病学会(APASL)4 + + >2×104 男女均<40 无炎症坏死或纤维化
    日本肝病学会(JSG)5 + + ≥2 000 男女均<30 排除其他因素所致ALT水平异常升高 无炎症坏死或纤维化
    中国6 >104 IU/mL + >2×107 ALT水平持续正常(1年内连续随访3次,每次至少间隔3个月) 无炎症坏死或纤维化
    下载: 导出CSV

    表  2  不同国家指南对CHB患者IT期监测标准及抗病毒治疗汇总

    Table  2.   Summary of indications of antiviral treatment in the different guildelines of AASLD, EASL, APASL, JSG and CMA

    地区 监测标准 抗病毒治疗时机
    AASLD2 正常的ALT(男性<30 U/L,女性<25 U/L)和高HBV DNA水平(≥20 000 IU/mL);每6个月监测ALT和HBV DNA水平 肝活检或无创检查提示重度炎症(≥A3)或显著纤维化(≥F2),特别是年龄>40岁;ALT水平持续升高(除外其他因素),仍保持HBeAg阳性且HBV DNA水平>20 000 IU/mL
    EASL3 正常的ALT(<40 U/L)和高HBV DNA水平(≥2 000 IU/mL);每3~6个月监测ALT和HBV DNA水平 年龄>30岁,或有肝硬化或者肝癌家族史或有肝外表现,或纤维化阶段使用肝活检或无创检查提示显著纤维化(≥F2)或中重度炎症(≥A2或更高),肝硬度值≥12 kPa,或ALT水平升高(除外其他因素)
    APASL4 正常的ALT(<40 U/L)和高HBV DNA水平(≥20 000 IU/mL);每3个月监测ALT和HBV DNA水平 年龄>35岁,或肝穿刺显示≥显著纤维化(≥F2)或重度炎症(≥A3),或无创检查有明显肝纤维化(肝硬度值≥8 kPa),或ALT水平持续升高(除外其他因素),或有肝硬化或者肝癌家族史
    JSG5 HBeAg血清学转换患者,无活动性炎症[即随访3次/年以上,并满足HBeAg持续阴性、ALT水平持续正常(<30 U/L)、HBV DNA<2 000 IU/mL 3个条件] HBeAg阳性,ALT水平异常升高但无纤维化进展和重症倾向者,建议随访1年左右再评估 ALT水平间歇性升高,或HBV DNA高,或血小板计数<15×104/μL且患者年龄>40岁,则建议确定肝纤维化(通过肝活检或无创检查)
    中国6 每隔6~12个月监测一次 符合下列情况之一:(1)有乙型肝炎肝硬化或HCC家族史;(2)年龄>30岁;(3)无创指标或者肝组织学检查,提示肝脏存在明显炎症(G≥2)或纤维化(F≥2);(4)HBV相关肝外表现(如 HBV相关性肾小球肾炎等)
    下载: 导出CSV
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