慢性乙型肝炎抗病毒治疗的困境和进展

慢性乙型肝炎(CHB)由乙型肝炎病毒(HBV)感染引起,易反复发作引起肝脏损伤,严重威胁人类健康。CHB治疗最根本、最关键的是抗HBV治疗,抗HBV治疗在近年来取得了很大的进展,基因治疗、免疫治疗等新技术为抗HBV治疗提供了新的发展方向,但抗HBV治疗仍面临难以突破的困境。本文就抗HBV治疗的困境和进展进行综述。     

正确认识慢性乙型肝炎的抗病毒治疗

全球现症乙型肝炎病毒(HBV)感染者约3．5亿, 每年有50-100万患者死于HBV感染相关疾病。慢性乙型肝炎(CHB)随着病情的进展而发生肝硬化和肝癌已是不争的事实,严重威胁人们的健康。近年,乙型肝炎抗病毒药物的研究进展较大,为临床医师提供了较多抗病毒治疗的选择;因而美国、欧洲、亚太地区及我国相继修订了乙型肝炎的防治指南,为临床医师的临床诊断治疗工作提供参考。     

Relationship between hepatitis B virus DNA levels and liver histology in patients with chronic hepatitis B

AIM： To study the relationship between hepatitis B virus （HBV） DNA levels and liver histology in patients with chronic hepatitis B （CHB） and to determine the prevalence and characteristics of hepatitis B e antigen （HBeAg） negative patients.
METHODS： A total of 213 patients with CHB were studied, and serum HBV DNA levels were measured by the COBAS Amplicor HBV Monitor test. All patients were divided into two groups according to the HBeAg status.The correlation between serum HBV DNA levels and liver damage （liver histology and biochemistry） was explored.
RESULTS： Of the 213 patients with serum HBV DNA levels higher than 10^5 copies/mL, 178 （83.6%） were HBeAg positive, 35 （16.4%） were HBeAg negative. The serum HBV DNA levels were not correlated to the age,history of CHB, histological grade and stage of liver disease in either HBeAg negative or HBeAg positive patients. There was no correlation between serum levels of HBV DNA and alanine aminotransferanse （ALT）,aspartate aminotrans-ferase （AST） in HBeAg positive patients. In HBeAg negative patients, there was no correlation between serum levels of HBV DNA and AST,while serum DNA levels correlated with ALT （r = 0.351, P = 0.042）. The grade （G） of liver disease correlated with ALT and AST （P 〈 0.05, r = 0.205, 0.327 respectively）in HBeAg positive patients. In HBeAg negative patients,correlations were shown between ALT, AST and the G （P 〈 0.01, and r = 0.862, 0.802 respectively）. HBeAg negative patients were older （35 ± 9 years vs 30 ±9 years, P 〈 0.05 ） and had a longer history of HBV infection （8 ± 4 years vs 6 ± 4 years, P 〈 0.05） and a lower HBV DNA level than HBeAg positive patients （8.4± 1.7 Log HBV DNA vs 9.8 ± 1.3 Log HBV DNA, P 〈0.001）. There were no significant differences in sex ratio,ALT and AST levels and liver histology between the two groups.
CONCLUSION： Serum HBV DNA level is not correlated to histological grade or stage of liver disease in CHB patients with HBV DNA mor     

Occult hepatitis B virus infection in Egypt

The emerging evidence of the potentially clinical importance of occult hepatitis B virus (HBV) infection (OBI) increases the interest in this topic. OBI may impact in several clinical contexts, which include the possible transmission of the infection, the contribution to liver disease progression, the development of hepatocellular carcinoma, and the risk of reactivation. There are several articles that have published on OBI in Egyptian populations. A review of MEDLINE database was undertaken for relevant articles to clarify the epidemiology of OBI in Egypt. HBV genotype D is the only detectable genotype among Egyptian OBI patients. Higher rates of OBI reported among Egyptian chronic HCV, hemodialysis, children with malignant disorders, and cryptogenic liver disease patients. There is an evidence of OBI reactivation after treatment with chemotherapy. The available data suggested that screening for OBI must be a routine practice in these groups of patients. Further studies needed for better understand of the epidemiology of OBI among Egyptian young generations after the era of hepatitis B vaccination.     

Replication of clinical hepatitis B virus isolate and its application for selecting antiviral agents for chronic hepatitis B patients

AIM： To establish a cell model harboring replicative clinical hepatitis B virus （HBV） isolates and evaluate its application in individualized selection of anti-HBV agents for chronic hepatitis B （CHB） patients.
METHODS： The full-length HBV genomic DNA from 8 CHB patients was amplified by polymerase chain reaction （PCR）. All the patients were treated with lamivudine for at least seven months and finally became resistant to lamivudine. The amplified HBV DNA fragments were inserted into pHY106 vectors by Sap Ⅰ digestion. The recombinant plasmids containing 1.1 copies of HBV genome were transiently transfected into Huh7 cell line, and the levels of HBsAg, HBeAg and intercellular HBV replicative intermediates were determined by ELISA and Southern blot analysis, respectively, with or without lamivudine and adefovir treatment. The antiviral treatment with adefovir was administered to the patients and analyzed in parallel.
RESULTS： A total of 25 independent HBV isolates were obtained from the sera of 8 patients, each patient had at least two isolates. One isolate from each individual was selected and subcloned into pHY106 vector, including 5 isolates with YVDD mutation and 3 isolates with YIDD mutation. All recombinant plasmids harboring HBV isolates were transfected into Huh7 cells. The results indicated that HBV genome carried in HBV replicons of clinical HBV isolates could effectively replicate and express in Huh7 cells. Adefovir, but not lamivudine, inhibited HBV replication both in vitro and in vivo, and in vitro inhibition was dose-dependent.
CONCLUSION： The novel method described herein enables individualized selection of anti-HBV agents in clinic and is useful in future studies of antiviral therapy for CHB.     

对现行慢性乙型肝炎治疗的评价

最近来自澳大利亚、希腊、意大利、西班牙、中国台湾、英国和美国等7个国家和地区的14名专家对现行慢性乙型肝炎治疗中的16个问题进行了讨论。1名荷兰专家提供了基础资料，但未参加会议。每名专家在治疗慢性乙型肝炎方面均有丰富的经验和临床背景，其主要研究领域包括免疫病理学、分子病毒学和抗病毒治疗等。会议分3个阶段进行：第一阶段，先由3个小组讨论会的主席向与会代表作专题报告和介绍研讨会的讨论框架；第二阶段，3个小组讨论会同时举行，由1名主席和4名专家参加，专家们在提供资料时报告方法学、病例数及预后，确定证据级别等；第三阶段，召开全体大会，所有14名专家一起审核小组讨论会的纪要，并对每一个问题逐一进行了讨论，然后无记名投票。     

拉米夫定治疗慢性重型肝炎疗效观察

将45例慢性重型乙型肝炎患者随机分为治疗组22例、对照组23例.治疗组在综合保肝治疗的基础上口服拉米夫定100mg、每日1次,对照组仅用综合保肝治疗,疗程均为1年;观察症状、体征、肝功能、血清HBVM和HBVDNA的变化.结果显示,治疗后两组患者症状体征均有一定程度的改善;治疗结束时,治疗组治愈好转率(95.45%)高于对照组(73.91%),病死率(4.5%)低于对照组(17.39%),P均＜0.05.治疗前治疗组13例HBVDNA阴性、9例阳性(650.47±597.22fg/ml),治疗后阴性者持续阴性,阳性者均逐渐转阴;对照组15例HBVDNA阴性、8例阳性(579.52±542.86fg/ml),治疗后阴性者6例阳转,阳性者持续阳性.治疗3个月时,治疗组ALT复常率高于对照组;治疗8个月后治疗组复发率4.7%(1/21),对照组为57.14%(8/14),P＜0.01.提示拉米夫定治疗慢性重型乙型肝炎可使病毒持久转阴,复发率和病死率低.     

Long-term clinical impact of occult hepatitis B virus infection in chronic hepatitis B patients

BACKGROUND/AIMS: Long-term clinical outcomes of occult hepatitis B virus (HBV) infection were studied. METHODS: Fifteen chronic hepatitis B patients were monitored for a median of 4.4 years (range 0.9-15.3) after hepatitis B surface antigen (HBsAg) seroclearance. Serum HBV DNA was measured by real-time detection polymerase chain reaction. Thirteen patients underwent liver biopsies at the end of follow-up and liver histology was evaluated by Ishak score. Liver HBV DNA was also measured for 12 patients. RESULTS: At the end of follow-up, HBV viremia was absent in 13 (87%) patients, and antibody titers to hepatitis B core antigen showed an inverse correlation with time from HBsAg seroclearance (r=-0.554; P=0.0040). However, all patients retained liver HBV DNA and tested positive for the covalently closed circular HBV DNA replicative intermediate. The hepatic HBV DNA loads had no relation to liver histology. Paired biopsies from 11 patients disclosed that each necroinflammatory score significantly improved after HBsAg seroclearance. Amelioration of liver fibrosis was also evident in eight (73%) patients (P=0.0391 by signed rank test). CONCLUSIONS: A long-standing but strongly suppressed HBV infection may confer histological amelioration after HBsAg seroclearance.     

乙型肝炎病毒基因分型及其临床意义

目的了解慢性乙型肝炎病毒(HBV)感染者HBV基因分型及其对慢性肝病的影响,为制定针对不同HBV基因型抗病毒的个体化方案提供分子病毒学依据。方法临床确诊的慢性乙型肝炎、乙型肝炎肝硬化及肝癌患者314例,采用RDB法对HBV进行基因分型检测。结果山西地区的200例慢性乙型肝炎患者所感染的HBV均为B和C基因型,分别占56%、26%,并存在混合感染(17%);C与B基因型患者相比,血清病毒载量高、肝脏损伤严重;混合感染的患者与单一基因型感染者相比病毒载量更高、肝损伤更严重;肝硬化患者感染的HBV主要为C基因型及B、C混合感染,且肝损害严重、病毒复制率高;肝癌患者中C基因型感染占42.19%,B、C混合感染占37.5%,B基因型感染可能与年轻患者肝癌的发生有关。结论B基因型HBV感染与C基因型及混合感染相比,病毒载量低、肝损害轻,但年轻患者应监测肝癌的发生;C基因型及混合感染的患者预后较差,肝硬化、肝癌发生率高,应进行积极有效的治疗,防止严重肝病发生。     

Safety of lamivudine treatment for chronic hepatitis B in early pregnancy

AIM: To evaluate the safety of lamivudine (LAM) treatment for chronic hepatitis B in early pregnancy.METHODS: A total of 92 pregnant women who received LAM treatment either before pregnancy or in early pregnancy were enrolled in this study. All of the pregnant women volunteered to take lamivudine during pregnancy and were not co-infected with hepatitis C virus, human immunodeficiency virus, cytomegalovirus, or other viruses. All infants received passive-active immunoprophylaxis with 200 IU hepatitis B immunoglobulin and three doses of 10 μg hepatitis B vaccines (0-1-6 mo) according to the guidelines for the prevention and treatment of chronic hepatitis B. Adverse events were observed throughout the entire pregnancy and perinatal period, and the effectiveness of lamivudine treatment for blocking mother-to-infant transmission of hepatitis B virus (HBV) was evaluated. All adverse events in mothers and infants during pregnancy and the perinatal period and the HBV mother-to-infant transmission blocking rate were compared with the literature.RESULTS: Among the 92 pregnant women, spontaneous abortions occurred in 11 cases, while 3 mothers had a second pregnancy after the initial abortion; 72 mothers delivered 73 live infants, of whom 68 infants were followed up for no less than 6 mo, and 12 mothers were still pregnant. During pregnancy, the main maternal adverse events were vaginitis (12/72, 16.7%), spontaneous abortion (11/95, 11.6%), and gestational diabetes (6/72, 8.3%); only one case had 1-2 degree elevation of the creatine kinase level (195 U/L). During the perinatal period, the main maternal adverse events were premature rupture of the membranes (8/72, 11.1%), preterm delivery (5/72, 6.9%), and meconium staining of the amniotic fluid (4/72, 5.6%). In addition, 2 infants were found to have congenital abnormalities; 1 had a scalp hemangioma that did not change in size until 7 mo, and the other had early cerebral palsy, but with rehabilitation training, the infant’s motor functions became totally normal at 2 years of age. The incidence of adverse events among the mothers or abnormalities in the infants was not higher than that of normal mothers or HBV-infected mothers who did not receive lamivudine treatment. In only 2 cases, mother-to-infant transmission blocking failed; the blocking rate was 97.1% (66/68), which was higher than has been previously reported.CONCLUSION: Lamivudine treatment is safe for chronic HBV-infected pregnant mothers and their fetuses with a gestational age of less than 12 wk or throughout the entire pregnancy.     

新疆维吾尔族慢性乙型肝炎患者HBV基因型分布及其特点

目的探讨新疆维吾尔族慢性乙型肝炎患者HBV基因型分布及其特点。方法采用型特异性引物巢式PCR法对127例维吾尔族慢性乙型肝炎患者进行基因分型,并测序验证。结果基因D型占39．4%（50/127）,基因B型占22．0%（28/127）,基因C型占16．5%（21/127）,基因BD混合型占9．4%（12/127）,基因CD混合型占8．7%（11/127）,基因BCD混合型占3．9%（5/127）; HBeAg阳性与HBeAg阴性的维吾尔族慢性乙型肝炎患者基因型分布,差异无统计学意义（x^2= 6．033,P＞0．05）;不同年龄维吾尔族慢性乙型肝炎患者HBV基因型分布差异无统计学意义（x^2= 3．137,P＞0．05）;不同性别维吾尔族慢性乙型肝炎患者HBV基因型分布差异亦无统计学意义（x^2= 8．058,P＞0．05）。结论新疆维吾尔族慢性乙型肝炎患者HBV基因型以D型占优势,其次可见B、C型及BD、CD、BCD混合型。同一疾病谱的慢性HBV感染者基因型分布可能与宿主HBeAg状态、年龄、性别无明显关系。     

拉米夫定治疗慢性乙型肝炎停药后的临床观察

探讨拉米夫定药后慢性乙型肝炎患者临床变化的意义。对34例停用拉米夫定的慢性乙型肝炎患者，在停药1月、3月、6月时检测血清ALT、HBeAg、抗－HBe、HBVDNA，观察其转变情况。拉米夫定治疗前、后出现HBeAg至抗－HBe转变者为另一组（A组），未出现ABeAg至抗－HBe转变者为一组（B组），对比两组患者停药1月、3月、6月时ALT、HBV标志的变化。结果显示停药1月、3月、6月时ALT异常经累加后A、B两组分别0％和18．52％（P＞0．05）、0％和33．33％（P＞0．05）、14．29％和59．26％（P＜0．05）；HBVDNA阳转率分别为0％和25．93％（P＞0．05）、0％和44．44％（P＜0．05）、28．57％和77．78％（P＜0．05）。表明随着停药时间的延长。病情复发者增加。血清HBeAg至抗－HBe转变可作为拉米夫定停药的一个标志。     

当今慢性乙型肝炎治疗实践对HBV核酸检测方法的新需求

乙型肝炎病毒感染引起的慢性乙型肝炎仍是威胁我国人民生命健康的重要问题.当前治疗慢性乙型肝炎以口服恩替卡韦、替诺福韦和丙酚替诺福韦等高耐药屏障的一线核苷(酸)类似物为主,可强效抑制病毒复制,减少肝硬化和肝细胞癌的发生率.然而当前临床实践中,在启动治疗、监测疗效及判定停药等方面,均存在一定困难或争议.实现慢性乙型肝炎的"精...     

Measurement of hepatitis B virus core-related antigen as predicting factor for relapse after cessation of lamivudine therapy for chronic hepatitis B virus infection

Background

Prolonged lamivudine therapy has two major problems: breakthrough hepatitis during treatment and relapse of aminotransferase (ALT) after cessation of the therapy. The aim of this study was to examine factors that could predict ALT flare after stopping lamivudine therapy.

Methods

We analyzed 22 Japanese patients with chronic hepatitis B infection, in whom lamivudine therapy was stopped after HBV DNA level had been gone undetectable (<3.7 LGE/ml) during at least six consecutive months. The post-treatment followed up was carried for 28 months in median (range 9–41). HBV core-related antigen (HBcrAg) assay was assessed using newly developed assay.

Results

After cessation of lamivudine therapy, 11 patients (50%) had relapsed (reactivation of serum ALT >80 IU/l, relapsers) and remaining 11 (50%) did not relapse (non-relapsers). In the univariate comparison of relapsers versus non-relapsers, HBcrAg level at lamivudine cessation point (4.5 ± 1.0 versus 3.4 ± 0.9; p = 0.0145) has been shown as a significant predictive factor for non-relapse. All patients with HBcrAg <3.0 log U/ml at the cessation point had no ALT flares. Multivariate analysis on effects of 10 factors (age, sex, cirrhosis, pretreatment ALT level, HBV DNA level, HBcrAg level, mean months till undetectable HBV DNA, duration of undetectable HBV DNA and HBcrAg level at lamivudine cessation point), indicated that HBcrAg level at lamivudine cessation point <3.4 log U/ml was the only independent predictive factor for absence of the post-treatment relapse.

Conclusions

HBcrAg level at lamivudine cessation point might be useful as a prognostic predictor of response to lamivudine therapy cessation. The measurement of HBcrAg is a useful additional test for monitoring chronic HBV infection.     

Long-term treatment outcomes of clevudine in antiviral-naive patients with chronic hepatitis B

AIM: To evaluate the treatment outcomes of clevudine compared with entecavir in antiviral-naive patients with chronic hepatitis B (CHB).METHODS: We retrospectively analyzed the clinical data of CHB patients treated with clevudine 30 mg/d and compared their clinical outcomes with patients treated with entecavir 0.5 mg/d. The biochemical response, as assessed by serum alanine aminotransferase (ALT) activity, virologic response, as assessed by serum hepatitis B virus DNA (HBV DNA) titer, serologic response, as assessed by hepatitis B e antigen (HBeAg) status, and virologic breakthrough with genotypic mutations were assessed.RESULTS: Two-hundred and fifty-four patients [clevudine (n = 118) vs entecavir (n = 136)] were enrolled. In clevudine-treated patients, the cumulative rates of serum ALT normalization were 83.9% at week 48 and 91.5% at week 96 (80.9% and 91.2% in the entecavir group, respectively), the mean titer changes in serum HBV DNA were -6.03 and -6.55 log₁₀ copies/mL (-6.35 and -6.86 log₁₀ copies/mL, respectively, in the entecavir group), and the cumulative non-detection rates of serum HBV DNA were 72.6% and 83.1% (74.4% and 83.8%, respectively, in the entecavir group). These results were similar to those of entecavir-treated patients. The cumulative rates of HBeAg seroconversion were 21.8% at week 48 and 25.0% at week 96 in patients treated with clevudine, which was similar to patients treated with entecavir (22.8% and 27.7%, respectively). The virologic breakthrough in the clevudine group occurred in 9 (7.6%) patients at weeks 48 and 15 (12.7%) patients at week 96, which primarily corresponded to genotypic mutations of rtM204I and/or rtL180M. There was no virologic breakthrough in the entecavir group.CONCLUSION: In antiviral-naive CHB patients, long-term treatment outcomes of clevudine were not inferior to those of entecavir, except for virologic breakthrough.     

小儿乙型肝炎的流行病学及诊治进展

中国是乙型肝炎的高发区,HBV母婴传播是我国人群感染HBV的主要传播途径之一。婴儿或儿童感染HBV,约15％～25％将发展为慢性乙型肝炎病毒携带者,是肝硬化和肝细胞癌的主要原因之一。本文对儿童乙型肝炎的流行病学、诊断以及治疗方面的进展进行综述。     

拉米夫定治疗慢性乙型肝炎2年临床试验的总结

目的 评估拉米夫定长期治疗慢性乙型肝炎的疗效和安全性,以及治疗过程中产生病毒变异的临床影响。方法 系多中心的双盲,随机、安慰剂对照的临床试验。４２９例ＨＢｓＡｇ和ＨＢｅＡｇ阳性的慢性乙型肝炎,按３：１随机分成拉米夫定治疗组和对照组,分别服用拉米夫定１００ｍｇ／ｄ和安慰剂共１２周,此后所有病人均服用拉米夫定,共观察２年,结果 治疗１２周,拉米夫定组血清ＨＢＶ ＤＮＡ累计阴转率（〈１．６ｐｇ／ｍｌ）为