拉米夫定联合抗结核药物治疗肺结核合并乙型肝炎病毒携带者的临床分析

目的探讨在抗结核治疗的基础上联合应用拉米夫定治疗肺结核合并乙型肝炎病毒（HBV）携带者肝损伤发生情况，及拉米夫定使用的疗程和疗效。方法将江西省胸科医院治疗前肝功能正常的初治肺结核合并慢性HBV携带者142例，通过随机数字表法分为拉米夫定治疗组73例（失访4例，69例获得随访）和对照组69例（失访6例，63例获得随访）。对照组抗结核治疗至满疗程后停药，拉米夫定治疗组在使用抗结核治疗的同时，应用拉米夫定治疗至18个月后停药，两组患者均随访24个月，定期检测肝功能，对两组患者不同时期肝损伤率、总肝损伤率、死亡率、HBV-DNA阴转率、结核病治愈率及失败率进行分析。使用SPSS13．0软件进行统计学处理，以7。检验或Fisher确切概率法对计数资料进行统计分析，P〈0．05为差异有统计学意义。结果拉米夫定治疗组患者4周内肝损伤率、总肝损伤率、死亡率分别为4．3％（3／69）、20．3％（14／69）、0．0%（0／69），均低于对照组19．0％（12／63）、49．2％（31／63）、7．9％（5／63）]，差异均有统计学意义（X2=7．064，P=0．007；X2=15．176，P=0．0001；Fisher确切概率法，P=0．023）。抗结核治疗结束时和随访结束时，拉米夫定治疗组患者HBVDNA阴转率E24．6％（17／69）、21．7％（15／69）]均高于对照组3．2％（2／63）、3．2％（2／63）]，差异均有统计学意义（X2=12．311，P=0．0005；X2=10．115，P=0．001）。拉米夫定治疗组患者结核病治愈率（89．9％，62／69）高于对照组（73．0％，46／63），差异有统计学意义（X2=6．277，P=0．012）；治疗失败率（4．3％，3／69）低于对照组（17．5％，11／63），差异亦有统计学意义（X2=5．972，P=0．015）。结论应用拉米夫定可降低慢性HBV携带者眼用抗结核药物所导致的肝损伤，使用18个月后停用相对安全，可为肺结核合并慢性HBV携带者应用拉米夫定治疗提供一定的临床依据。

Clinical analysis of lamivudine combined with anti-tuberculosis drugs in treating pulmonary tuberculosis complicated with hepatitisBviruscarriers

Objective To explore the effect of lamivudine therapy on pulmonary tuberculosis patients with hepatitis B virus carriers based on anti TB treatment, including the incidence of liver injury, the treatment time and long-term effects Methods One hundred and forty two new pulmonary tuberculosis patients with chronic hepatitis B virus carriers who had normal liver function were randomly divided into lamivudine group （73 patients, 4 cases were lost to follow-up） and control group （69 patients, 6 cases were lost to follow-up）. By the end of 18 month treatment, lamivudine would be stopped, but anti-tuberculosis drugs were not stopped until the treatment ended. All the patients of both groups were followed up for 24 months, liver injury rate within 4 weeks, the total liver injury rate, HBV DNA negative rate, mortality, TB cure rate, failure rate were analyzed by Chi-square test or Fisher＇s exact probability method. Results Patients treated with lamivudine significantly reduced liver injury. Liver injury rate within 4 weeks, the total liver injury rate and mortality of the lamivudine group were lower than the control group. There were significant differences between lamivudine group （4.3 % （ 3/69 ）, 20.3% （14/69）, 0.0 % （0/69） ; P=0.007, 0.0001, 0.023, X2=7.064,15.176） and control group （19.0% （12/63）, 49.2% （31/63）, 7.9% （5/63））. At the end of TB treatment and the end of follow up period, the HBV DNA negative rate of lamivudine group （24.6%（17/69）,21.7%（15/69）） was higher than control group （3.2% （2/63）, 3.2%0 （2/63））, the difference was statistically significant （X2=12. 311 ,P=0. 00051 and X2 =10.115,P=0. 001）. TB cure rate of larnivudirle group was higher than control group （89.9% vs 73.0%） and the failure rate lamivudine group were lower than the control group （4.3% vs 17.5%）, There were significant differences between 2 groups. Conclusion Using lamivudine within 18 months is relatively safe for reducing the incidence of hepatitis B, which has a long term effect. Our findings can provide a clinic basis for prophylactic lamivudine therapy on pulmonary tuberculosis patients with HBV infection.