乙型肝炎病毒相关性肾炎临床诊断的探讨

目的　探讨乙型肝炎病毒相关性肾炎 (HBV GN)的临床诊断的可靠性。方法　对经临床诊断为HBV -GN患儿进行肾穿病理检查 ,比较临床诊断和病理诊断的符合度及两组临床特征的差异。结果　临床诊断为HBV -GN患儿行肾活检分析 ,69例符合病理诊断标准 ,2 9例排除HBV- GN。HBV GN临床诊断和病理诊断高度相关 ,有显著差异P <0 .0 1 ,HBV GN临床诊断的敏感性 94.5 % ,特异性 93 .2 % ,准确性 93 .4 % ,漏诊率 5 .5 % ,误诊率 6 .8%。临床与病理诊断符合组与不符合组年龄、HBV标志分布上有显著性差异 ,诊断符合组中 <6岁患儿比例高于诊断不符合组 (58%vs 1 4 % ) ,HBV大三阳 (HBsAg、HBeAg和HBcAg阳性 )比例也高于诊断不符合组 (80 %vs 66 % ) ,有显著性差异P <0 .0 5 ,而其他临床表现无显著性差异。结论　HBV GN临床诊断有较大的实用价值 ,可用于基层医院 ,但在应用时应注意此诊断方法有少量漏诊和误诊。     

儿童乙型肝炎病毒相关性肾炎74例临床病理分析

目的探讨儿童乙型肝炎病毒相关性肾炎（HBV-GN）的临床和病理特点。方法收集经肾活检确诊为HBV—GN的74例患儿入院时临床表现（水肿、血压）及实验室检查结果（尿常规、24h尿蛋白定量、乙肝5项、血清清蛋白、血HBVDNA等），并对其肾组织进行光镜（常规染色及特殊染色）及免疫组织化学检查（IgG、IgA、IgM、C3e、C4e、HBsAg、HBcAg）。根据血清HBVDNA水平不同将74例HBV—GN患儿分为高病毒载量组（HBVDNA〉1．0&#215;10^8copies／L）58例和低病毒载量组（HBVDNA〈1．0&#215;10^8copies／L）16例，并比较分析其临床病理特点。结果临床表现：肾病综合征（NS）52例（70．3％）；血尿和蛋白尿13例（17．6％）；单纯性蛋白尿6例（8．1％）；单纯性血尿3例（4．1％）。病理分型：膜性肾病（MN）56例（75．7％）；系膜增生性肾小球肾炎（MsPGN）12例（16．2％）；膜增生性肾小球肾炎（MPGN）5例（6．6％）；毛细血管内增生性肾小球肾炎（EnPGN）1例。高病毒载量组与低病毒载量组入院时血清清蛋白[（22．04&#177;7．69）g／L vs（31．95&#177;5．83）g／L]，C3[（0．759&#177;0．252）g/L vs （0．986&#177;0．330）g／L]比较均有统计学差异（Pa〈0．05）。高病毒载量组病理类型多样，而低病毒载量组相对单一，以MsPGN、MN为主。结论HBV—GN患儿学龄期多见，且男多于女，临床表现以NS为主，病理类型以MN多见，血清HBVDNA水平与HBV—GN病变密切相关。     

儿童乙型肝炎病毒相关性肾炎临床病理分析

目的 探讨儿童乙型肝炎病毒相关性肾小球肾炎(HBV—GN)临床及病理特点。方法 分析35例HBV—GN的临床表现及肾活检光镜、免疫荧光和电镜特点。结果 35例HBV-GN临床表现以肾病综合征(NS)为主(32／35，91．4％)；肾小球肾炎3／35(8．6％)。病理类型以膜性肾病(MN)最多见(33／35，94．3％)；其次系膜增生性肾炎(MsPGN，2／35，5．7％)。免疫荧光检查呈多种免疫复合物沉积。电镜观察HBV—MN易见电子致密物系膜沉积，2例肾小球基底膜内观察到病毒样颗粒。结论 儿童HBV—GN临床常表现主要为NS，病理特征以Ⅲ为主，诊断不必强调HBsAg、HBcAg在肾组织上沉积，肾组织病理特点提示HBV可通过多种机制引起肾损害。     

乙型肝炎病毒相关性肾炎临床病理分析

目的探讨儿童乙型肝炎病毒相关性肾炎(HBV-GN)的临床和病理特点。方法对经肾活检确诊HBV-GN患儿73例的临床及病理特点进行分析。本组男66例,女7例。发病年龄1~14岁,平均6.5岁。占同期肾活检14.4%(73/508)。结果临床表现为肾病综合征(NS)53例(72.6%)、肾炎综合征15例(20.5%)、蛋白尿和血尿5例(6.9%);血清HBV感染标志物均阳性,其中大三阳55例(75%),小三阳14例(19.2%),HBsAg及抗HBc阳性2例,HBsAg及HBeAg阳性、仅抗HBc阳性各1例。病理分型:膜性肾病(MN)69例(94.5%),系膜增生性肾炎(MsPGN)及膜增生性肾炎(MPGN)各2例(各2.7%),表现为NS者病理改变全部为MN,临床表现与MN病理分级间存在显著线性关联(χ2=5.22 P=0.022)。结论儿童HBV-GN病理以MN为突出特征,临床表现以NS为主,临床表现与病理改变有一定关联。     

乙型肝炎病毒相关性肾炎药物治疗的Meta分析

目的 乙型肝炎病毒相关性肾炎（HBV-GN）是最常见的继发性肾小球疾病之一，目前尚无统一的治疗方案，本研究对HBV GN药物治疗的疗效进行Meta分析，以期为临床治疗提供参考。方法检索PubMed、EMBASE、Cochrane Library、中国生物医学文献数据库、中国期刊全文数据库和学术会议论文汇编、学位论文集，收集关于HBV-GN药物治疗的中、英文文献。应用国际Cochrane中心推荐的方法进行文献质量评价。使用STATA 9.0和RevMan 4.2软件进行Meta分析，计算治疗组与对照组缓解率的相对危险度（RR）及其95%CI，并对不能进行Meta分析的数据进行描述性分析，系统评价各种治疗方案的疗效。结果共检出中、英文文献978篇，依据纳入和排除标准，最终有9篇文献（英文8篇，中文1篇）纳入本研究，其中仅1篇为3分的RCT，其余均为队列研究。抗病毒治疗的疗效分析共纳入6项研究（1项为单中心RCT，5项为队列研究），其中4项研究以重组人干扰素-α（rIFN-α）进行治疗，1项以拉米呋啶进行治疗，另1项包括了上述两种治疗，纳入患者159例（抗病毒治疗组72例，对照组87例）。临床应答的Meta分析显示：RR=1.69，95%CI：1.08~2.65，抗病毒治疗组蛋白尿缓解率（91.0%）高于对照组（56.0%），两组差异有统计学意义（P=0.02）；儿童亚组分析显示抗病毒治疗组蛋白尿缓解率（86.7％）与对照组（61.1％）差异无统计学意义。病毒学应答的Meta分析显示：RR=6.44，95%CI：3.11~13.35，抗病毒治疗组的HBeAg阴转率（59.7%）高于对照组（8.33%），两组差异有极显著统计学意义（P<0.000 01）；儿童亚组分析结果一致，且一致性检验发现血中HBeAg的清除与蛋白尿缓解呈显著相关（kappa=0.285, P=0.002）。糖皮质激素治疗的疗效分析共纳入5项研究，均为队列研究，纳入患者76例（激素治疗组37例，对照组39例）。临床应答的Meta分析显示：RR=1.45，95%CI：0.68~3.11，激素治疗组与对照组蛋白尿缓解率的差异无统计学意义（P=0.34），儿童亚组分析结果一致。结论已有多种药物被用于治疗HBV-GN，但迄今为止最佳的治疗方案尚无定论。本研究显示抗病毒（包括rIFN-α和拉米夫啶）治疗HBV-GN能有效缓解蛋白尿、抑制HBV复制，且HBeAg的清除与蛋白尿的缓解密切相关；并能在一定程度上延缓肾功能恶化的发生；大多数患者耐受性好。而糖皮质激素治疗HBV-GN，其预后无明显改善。由于受限于原始研究的质量、数量以及各研究间治疗方案的差异，上述结论仅供临床医生参考，确切的结论有待今后由多中心、大规模RCT研究获取更多高质量EBM证据对本系统评价进行更新。     

儿童乙型肝炎病毒相关性肾炎的治疗

乙型肝炎病毒(HBV)相关性肾炎(HBV-GN)的治疗应根据HBV感染状况和蛋白尿水平、肾脏病变程度综合考虑,由于该病在成人多迁延不愈,但在儿童有一定的自然缓解倾向,因此治疗上应与成人患者有所区别,目前仍以抗病毒和对症治疗为主,对表现为肾病综合征且抗病毒治疗效差者才考虑使用皮质激素等免疫抑制治疗.     

儿童乙型肝炎病毒相关性肾炎的流行病学

乙型肝炎病毒(HBV)感染不仅可导致慢性肝炎、肝硬化和肝癌,HBV相关性肾炎也是我国儿童继发性肾损害的主要原因之一.1992年1月1日,我国卫生部在全国推行新生儿乙肝疫苗接种.目前我国出生即接种乙肝疫苗的1-13岁儿童,HBsAg平均阳性率相似文献   

儿童血清学阴性乙型肝炎病毒相关性肾炎13例临床与病理分析

目的 回顾性分析儿童血清学阴性乙型肝炎病毒相关性肾炎（sn HBV-GN）的临床及病理学特征,并初步探讨免疫抑制剂治疗的安全性和有效性。方法 收集 2006 年 1 月至 2011年12月经首都医科大学附属北京儿童医院肾活检诊断为HBV-GN病例,根据血清学结果筛选出HBsAg和HBV-DNA阴性患儿,分析其临床、病理资料和治疗情况。结果 13例sn HBV-GN患儿进入分析,男8例,女5例,平均年龄11.8岁。临床表现以肾病综合征为主（11例）,9例伴有血尿;2例表现为肾炎综合征。①11例以不典型膜性肾病为主要病理表现,免疫荧光以IgG、C3沉积为主, 亦可见IgA、IgM、C1q沉积。②肾组织HBsAg与HBcAg阳性率分别为100%（13/13）和76.9%（10/13）,强阳性率分别为23.1%（3/13）和15.4%（2/13）。③2例肾炎综合征患儿经抗凝和卡托普利治疗完全缓解;11例肾病综合征患儿,单纯抗病毒治疗2例均未缓解;单纯糖皮质激素治疗2/3例部分缓解,糖皮质激素加环孢素治疗2/3例部分缓解,糖皮质激素加用麦考酚酸酯治疗3例均完全缓解。加用免疫抑制剂患儿均未发现肝功能异常及HBV-DNA活动表现。结论儿童sn HBV-GN的病理以不典型膜性肾病为主要表现;免疫荧光显示免疫复合物的种类少,沉积强度低;麦考酚酸酯联合激素治疗较单用激素或激素联合环孢素治疗可能有效,单纯抗病毒治疗可能无效。     

乙型肝炎病毒相关性肾炎患儿的肝脏病变

目的：乙型肝炎病毒相关性肾炎(HBVGN)是我国常见的继发性肾小球疾病之一,以往人们只关心HBVGN时肾脏病变的问题,对无明显肝脏临床症状的“病毒携带者”或轻微的临床患者的肝脏的情况没有引起注意。该文探讨HBVGN时肝脏的病理变化。方法：选择13例HBVGN患儿同时进行肝肾病理活检。结果：13例患儿均有肝组织不同程度的受累,主要以轻度肝脏病理改变为主(9/13,占69.2%),HBV抗原在肝组织中主要以HBsAg检出率为高(10/13例,占76.9%);肾病理改变以膜性肾病为主(9/13,占69.2%),其次为系膜增生性肾炎(4/13例,占30.8%),HBV抗原在肾组织HBsAg和HBcAg的检出率均达100%,几乎所有的肾小管间质中有HBV抗原成分的分布。肝组织与肾组织中同时出现HBcAg的有4例。结论：HBVGN患儿均有不同程度的肝损害,而肾及肝组织病理改变不一定呈平行关系,肝组织与肾组织中同时出现HBcAg时肝肾同时损害均较重。提示对于HBVGN患者要重视肝肾同治。     

Treatment results of chronic hepatitis B in children: a retrospective study

In this retrospective study, we aimed to share our experience with different treatment modalities for chronic hepatitis B in a series of children. The study included 126 children (mean: 9.5 +/- 3.8 years). Normalization of alanine aminotransferase (ALT), loss of hepatitis B virus (HBV)-DNA and hepatitis B e antigen (HBeAg), and development of antibody to HBeAg (anti-HBe) altogether at the end of the treatment was considered as end of therapy response (ETR). Seroconversion ongoing one year after the cessation of therapy was considered as sustained response. Of the total children, 90 (71.4%) were treated, whereas the remaining were just followed-up. High-dose interferon (IFN)-alpha (10 MU/m2) alone, standard-dose IFN-alpha (6 MU/m2) plus lamivudine (4 mg/kg/d), high-dose IFN-alpha plus lamivudine, or lamivudine alone was used, IFN-alpha thrice weekly for six months, and lamivudine daily for one year. Of children who had completed their treatment, 34 (37.8%) achieved ETR. Sustained response rate was 36.7%. Response rates were different in the different treatment groups (p: 0.01). The highest response rate was observed in those who received standard-dose IFN-alpha plus lamivudine treatment (61.5%). Of children without treatment, one (2.8%) had anti-HBe seroconversion. Standard-dose IFN-alpha plus lamivudine treatment was found superior to the other treatment modalities. Predictors of ETR were similar to those found in previous studies.     

尿中乙型肝炎病毒DNA检测对小儿乙肝相关性肾炎诊断价值研究

目的　探讨尿中乙肝病毒DNA(HBV DNA)的检测对诊断小儿乙肝病毒相关性肾炎 (HBV GN)的意义。方法　应用聚合酶链式反应 (PCR)、免疫荧光 (IF)及原位杂交法 (ISH)检测患儿血清和尿中HBV DNA及肾活检石蜡包埋组织切片中HBV抗原与HBV DNA的存在状况。结果　 32例患儿经血清HBV DNA与肾组织中HBV抗原检测 ,符合HBV GN诊断的 19例 ,其中 11例经ISH检测发现肾活检石蜡包埋组织切片中HBV DNA阳性 ,13例尿HBV DNA阳性 ,阳性率分别为 5 7 9%、6 8 5 %。结论　检测肾小球疾病患儿尿中HBV DNA可协助HBV GN的临床诊断     

HLA typing associated with hepatitis B E antigen seroconversion in children with chronic hepatitis B virus infection: a long-term prospective sibling cohort study in Taiwan

OBJECTIVE: To conduct a prospective cohort study to clarify the relationship between human leukocyte antigen (HLA) polymorphisms and the seroconversion of hepatitis B e antigen (HBeAg). STUDY DESIGN: In the prospective cohort study, 81 HBeAg-positive children with chronic hepatitis B virus (HBV) infection from 40 unrelated families were recruited and followed-up regularly for a mean period of 17.70 +/- 3.23 years. The association between HLA antigen and the age at HBeAg seroconversion was analyzed using Cox regression model with shared frailties under left truncation and right censorship. RESULTS: HLA-B61 and HLA-DQB1*0503 antigens predicted a higher HBeAg seroconversion rate (relative incidence = 6.17 and 3.22, P = .024 and .017, respectively). Within-family frailty in our sibling cohort study demonstrated a negligible or a low degree of within-family correlation with spontaneous HBeAg seroconversion in each HLA antigen. CONCLUSIONS: HLA class I antigen B61 and class II antigen DQB1*0503 are associated with earlier HBeAg seroconversion in Taiwanese children with chronic HBV infection.     

检测尿HBV抗原诊断乙型肝炎相关性肾炎的价值

探讨检测尿乙型肝炎病毒（ＨＢＶ）抗原诊断乙型肝炎相关性肾炎的价值。肾小球病伴尿ＨＢＶ抗原阳性者可临床诊断乙肝肾炎。     

Combined lamivudine/interferon-alpha treatment in "immunotolerant" children perinatally infected with hepatitis B: a pilot study

OBJECTIVE: To investigate whether combining the antiviral effect of lamivudine with the immune-boosting action of interferon-alpha (IFN-alpha) is effective in treating hepatitis B virus (HBV) "immunotolerant" children. STUDY DESIGN: Twenty-three children (8 boys; mean age, 10 years) infected during the first year of life (17 Asian, 21 with normal aminotransferase levels, 15 with HBV-DNA >1000 pg/mL by hybridization and all with mild histologic changes) were treated with lamivudine (3 mg/kg) for 8 weeks alone and then lamivudine (3 mg/kg) and IFN-alpha (5 MU/m(2), 3 times weekly) in combination for 10 months. RESULTS: Seventy-eight percent became HBV-DNA negative at the end of treatment, 5 (22%) seroconverted to anti-HBe, 4 (17%) of whom achieved complete viral control, becoming persistently HBsAg negative and anti-HBs positive. None had YMDD mutations. The viral status of the patients has not changed after a median follow-up of 40 months (range, 36 to 48). CONCLUSIONS: This pilot study suggests that lamivudine pretreatment followed by a combination of lamivudine and IFN-alpha can induce complete viral control in HBV immunotolerant children, hitherto considered poor responders.     

Hepatitis B immunoglobulin in combination with lamivudine for prevention of hepatitis B virus reactivation in children undergoing bone marrow transplantation

There is little information in literature about the use of hepatitis B immunoglobulin (HBIg) in recipients of bone marrow transplantation (BMT). Here, we report two children who received IV HBIg (Hepatect-CP) and lamivudine treatment during BMT course for either patient or donor hepatitis B virus (HBV) viremia. A four-year-old girl underwent a fully human leukocyte antigen-matched allogeneic BMT for thalassemia major from her mother positive for hepatitis B surface antigen (HBsAg). A 12-yr-old boy with chronic myeloid leukemia, positive for HBsAg and HBV-DNA received a fully HLA-matched allogeneic BMT from his sister in the first chronic phase of the disease. HBIg was successfully used in both cases to prevent HBV reactivation of the recipients. The results of our observations are encouraging and we suggest that HBIg in combination with lamivudine may be used in such cases especially in post-transplant early period to prevent HBV reactivation.     

Post-streptococcal glomerulonephritis in Sydney: a 16-year retrospective review

AIM: Post-streptococcal glomerulonephritis (PSGN) is a frequent cause of acute nephritis in children. Numerous studies have described PSGN in high-risk populations yet few data describing PSGN in a low-incidence population exist. This study aimed to describe the epidemiology, clinical manifestations, diagnosis, complications and outcomes of PSGN in an urban Australian population. METHODS: A 16-year retrospective review of case notes and laboratory data was conducted at a tertiary Sydney paediatric hospital. RESULTS: Thirty-seven children were treated for PSGN with a mean age of 8.1 years (range 2.6-14.1 years). Twenty-eight subjects (75.7%) had a history of a recent upper respiratory tract or skin infection. Hypertension and/or oedema was present in 29 subjects (78.4%). Streptococcal pharyngitis was identified as the likely source in 17 subjects (45.9%). Skin infections occurred less frequently. Antibodies against streptolysin O, streptokinase or deoxyribonuclease B were elevated when a single titre was measured in 35 subjects (94.6%). Thirty subjects (81.1%) developed renal impairment (median peak creatinine, 95 micromol/L, range 39-880 micromol/L). No correlation was demonstrated between peak creatinine, age, ethnicity, streptococcal titres and serum complement levels. The mean length of admission was 8.2 days. Seven subjects (18.9%) had a complicated course with three subjects requiring dialysis. Only one subject has ongoing renal dysfunction. CONCLUSION: Significant differences are seen in a low-incidence urban Australian population with PSGN when compared with endemic or epidemic disease in high-risk populations. The higher rates of complications that were seen compared with previously studied populations need further clarification.     

苦参素联合拉米呋啶佐治慢性乙型病毒性肝炎35例

我们于 2 0 0 2年 5月～ 2 0 0 3年 5月用苦参素联合拉米呋啶治疗儿童慢性乙型病毒性肝炎 (乙肝 ) 3 5例 ,取得较好疗效 ,现报道如下。对象与方法一、对象　 2 0 0 2年 5月～ 2 0 0 3年 5月我院门诊收治的慢性乙肝 60例 ;均符合 1995年第 5届全国传染病与寄生虫病学术会议慢性乙肝诊断标准[1];均有乏力、纳差、腹胀 ,其中右上腹疼痛 54例。丙氨酸氨基转移酶 (ALT)升高 42例(47～ 10 0U/L 2 7例 ,～ 3 0 0U/L 10例 ,>3 0 0U/L 5例 ) ,胆红素升高 9例。随机分为治疗组和对照组。治疗组 3 5例 ,男19例 ,女 16例 ;年龄 6～ 15岁。对照组 2 5…