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关于《扩大慢性乙型肝炎抗病毒治疗的专家意见》的几点思考

刘智泓 梁携儿 侯金林

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关于《扩大慢性乙型肝炎抗病毒治疗的专家意见》的几点思考

DOI: 10.3969/j.issn.1001-5256.2023.01.002
利益冲突声明:所有作者均声明不存在利益冲突。
作者贡献声明:刘智泓负责查找文献,撰写文稿;梁携儿负责审阅文稿;侯金林负责审阅文稿及最后定稿。
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    侯金林,jlhousmu@163.com (ORCID: 0000-0001-8230-8583)

Thoughts on expert opinion on expanding antiviral therapy for chronic hepatitis B

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    Corresponding author: HOU Jinlin, jlhousmu@163.com (ORCID: 0000-0001-8230-8583)
  • 摘要: 扩大抗病毒治疗是目前慢性乙型肝炎诊疗的新趋势,相关的研究证据值得学习和讨论。其中,降低启动抗病毒治疗的ALT阈值是扩大治疗中最重要的变化之一。ALT低水平升高或正常水平高值的慢性乙型肝炎患者仍具有更高的肝癌风险,因此需要进一步干预。现有核苷(酸) 类似物(NUC)对该部分患者的病毒学抑制和纤维化改善有效,而降低ALT阈值则将对治疗后的生化学应答提出了更高的要求。另一方面,虽然经治低病毒血症(LLV)的机制和定义仍未充分明确,但进一步干预LLV是在临床实践中优化患者管理的重要策略。换用另一种强效的NUC可能会进一步提高LLV患者病毒应答率,而联合干扰素或其他新靶点药物将是未来治疗LLV的重要研究方向。

     

  • 图  1  一种开展临床研究、评价临床证据的思维框架

    Figure  1.  A thinking framework for conducting clinical research and evaluating clinical evidence

    表  1  不同地区CHB诊疗指南中对于非肝硬化患者启动抗病毒治疗的推荐意见(经原文作者同意后转载,有修订[4])

    Table  1.   Recommendations for initiating antiviral therapy in patients with non-cirrhosis in the regional guidelines for the diagnosis and treatment of chronic hepatitis B(reproduced with the consent of the original author, with revision[4])

    诊疗指南 定义人群 血清HBV DNA水平 血清ALT水平 肝脏疾病严重程度 推荐意见(根据原文翻译)
    无创纤维化诊断 肝组织活检
    EASL 2017[5] 慢性肝炎(HBeAg+/-) > 20 000 IU/mL > 2×ULN (80 U/mL) 无论肝纤维化程度如何 启动治疗
    > 2000 IU/mL > ULN (40 U/mL) 需要至少存在中度的炎症坏死或纤维化
    慢性病毒感染 > 2000 IU/mL 持续正常 可用于临床决策 至少中度纤维化 可能需要治疗
    HBeAg(+)的慢性感染(免疫耐受期) 高病毒载量 持续正常 无论组织学严重程度如何 若年龄 > 30岁或具有肝硬化/HCC家族史,可以予以治疗
    AASLD 2018[6] 免疫活动的HBeAg(+) CHB > 20 000 IU/mL ALT > 2×ULN (男性:35 U/L,女性:25 U/L) 或存在显著的组织学改变 治疗
    免疫活动的HBeAg(-) CHB > 2000 IU/mL
    其他免疫活动人群 符合相应的界值 1~2×ULN 需要考虑肝脏疾病的严重程度
    低于相应的界值 若年龄 > 40岁,或具有HCC家族史,既往治疗史或肝外表现则需要治疗
    免疫耐受期 ≥1 000 000 IU/mL ALT正常 存在显著炎症坏死或纤维化 治疗
    APASL 2015[7] HBeAg(+) > 20 000 IU/mL > 2×ULN 需要肝活检或无创诊断 若3个月内未发生血清学转换则启动治疗
    HBeAg(-) > 2000 IU/mL
    其他慢性HBV感染人群 低于定义的界限 若无创诊断结果提示显著纤维化且ALT持续升高,年龄 > 35岁或具有肝硬化/HCC家族史 若肝活检提示中至重度的坏死性炎症或显著纤维化及以上则需要启动抗病毒治疗
    中国2019[2] 慢性HBV感染 阳性 ALT持续 > ULN 建议抗病毒治疗
    阳性 ALT正常 肝组织提示明显的炎症或纤维化;或存在肝硬化/HCC家族史且年龄 > 30岁;或HBV相关肝外表现则建议抗病毒治疗
    注:EASL,欧洲肝病学会;AASLD,美国肝病学会;APASL,亚太肝病学会。
    下载: 导出CSV
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