病毒性肝炎抗病毒治疗进展

我国是病毒性肝炎的高发区，尤其是乙型病毒性肝炎，全国约有1．2亿乙型肝炎病毒携带者．其中需接受抗病毒治疗的慢性乙型肝炎患者约2000万。而我国HCV感染率占总人口的3．2％左右．总数约为4200万，其中多数为慢性持续性感染。众所周知，病毒性肝炎病情发展有三步曲，即肝炎、肝硬化、肝癌。     

拉米夫定对乙肝合并肺结核病患者抗结核的临床观察

目的观察拉米夫定抗病毒治疗对乙型肝炎合并肺结核患者在抗结核化疗过程中的临床作用。方法选择45例乙型肝炎合并肺结核患者,随机分为两组：抗病毒治疗＋护肝治疗＋抗结核治疗组（A组）、护肝治疗＋抗结核治疗组（B组）,观察治疗前后肝功能和HBV DNA变化情况。结果 B组肝功能明显高于A组,差异有统计学意义（P〈0.05）;且B组停药率明显高于A组（P〈0.05）,B组HBVDNA水平明显较A组升高（P〈0.05）。结论拉米夫定抗病毒治疗能抑制乙肝病毒的复制,防止乙肝病情的加重,从而明显减轻乙肝合并肺结核患者抗结核过程中出现的肝脏功能损害情况。     

慢性乙型病毒性肝炎选用不同抗病毒药物临床疗效观察

目的临床观察拉米夫定和阿德福韦酯及干扰素治疗慢性乙型病毒性肝炎的疗效及不良反应。方法随机应用单一抗病毒口服药拉米夫定治疗24个月患者43例、应用阿德福韦酯治疗24个月患者41例,联合应用阿德福韦酯及干扰素-α患者36例。分别记录并对比三组患者治疗6个月、12个月、18个月、24个月时疗效及不良反应。结果三组病例在治疗各时段肝功能明显改善、血HBV-DNA水平大幅下降、乙肝标志物的阴转率增高。病毒变异发生率以拉米夫定治疗组最高（P〈0.01）。联合治疗组在肝功能改善、血HBV-DNA水平降低、乙肝标志物的阴转率等各方面均优于前两组单一口服用药组,差异显著（P〈0.01）。结论阿德福韦酯保护肝功能、抑制病毒复制效果良好而不易发生病毒变异。与干扰素联合使用,安全有效,明显提高乙肝标志物的阴转率和治疗成功率。     

慢性乙型病毒性肝炎肝衰竭抗病毒治疗的利与弊

抗病毒治疗通过抑制患者体内乙型肝炎病毒(HBV)HBV DNA的复制,有效延缓、阻断甚至逆转疾病进展,是目前慢性乙型肝炎患者(CHB)的基本治疗方式。口服核苷(酸)类似物[nucleoside(tide)analogues,NAs]疗效强、安全性高,是CHB治疗道路中的重大里程碑。然而对于肝脏功能及整体状况严重恶化的HBV相关肝衰竭患者,抗病毒治疗是否可以改善预后甚至挽救生命,这类患者在抗病毒时机、药物及治疗方案上应如何选择,仍然存在诸多争议。本文结合最新的循证学证据对上述问题进行总结和分析,提出对于各时期、各类型的HBV相关肝衰竭患者,总体上都应及时进行抗病毒治疗,同时需建立完善的评估监测系统准确把握治疗时机,并通过联合其他治疗方式提高抗病毒的有效性和安全性。     

慢性乙型病毒性肝炎临床抗病毒治疗的难点与对策

慢性乙型病毒性肝炎(以下简称乙型肝炎)是由乙型肝炎病毒(HBV)引起的以肝脏进行性损害为主的慢性传染病。我国是乙型肝炎的发病大国,每年因乙型肝炎损失大量的工作日和劳动力,还有几十万人死于乙型肝炎引起的终末期肝病如失代偿性肝硬化、肝细胞癌或重型肝炎[1]。勿庸讳言,乙型     

慢性乙型肝炎抗病毒治疗的研究进展

抗病毒治疗是慢性乙型病毒性肝炎治疗的核心问题之一。本文就慢性乙型病毒性肝炎抗病毒药物的研究进展、联合治疗的现状以及目前抗病毒治疗存在的问题和可能的对策作一综述。     

不同病情CHB伴肺结核患者抗病毒联合抗结核治疗中肝损伤情况观察及临床意义

背景 慢性乙型肝炎(chronic hepatitis B, CHB)伴结核病患者确诊后需及时进行抗病毒、抗结核治疗,但由于疗程较长,应用药物较多,治疗过程中易发生肝损伤,影响治疗结局.本文对治疗中肝损伤进行研究探讨,为临床防治肝损伤提供参考.目的 探讨不同病情CHB伴肺结核患者抗病毒+抗结核治疗中肝损伤情况及临床意义,以期为临床预防肝损伤提供理论依据.方法 选取2017-12/2022-12我院收治的200例CHB伴肺结核患者,均给予抗病毒联合抗结核治疗,统计患者抗结核治疗完成情况与肝损伤发生情况.比较乙型肝炎表面抗原(hepatitis B surface antigen, HBs Ag)阳性与阴性、不同肝组织炎症坏死分级和纤维化程度患者治疗前后肝生化变化及肝损伤发生情况,应用Spearman分析肝组织炎症坏死分级和纤维化程度与肝生化异常项目数关系.结果 (1)200例CHB伴肺结核患者抗病毒+抗结核治疗中共发生肝损伤97例,总发生率为48.50%(97/200), 69例经过更改抗结核药物和护肝处理完成标准疗程治疗, 28例经更改抗结核药物和护肝处理后肝生化仍无好转,暂停抗结核治...     

乙型肝炎病毒基因变异对慢性乙型肝炎患者病情发展及抗病毒治疗的影响

目的 探讨乙型肝炎病毒(HBV)基因变异对慢性乙型肝炎(慢乙肝)患者病情发展、严重程度以及对抗病毒治疗疗效的影响。方法 采用基因芯片技术，对选取的部分乙型肝炎患者进行HBV基因变异位点的检测。结果 α-干扰素治疗24周以上，HBeAg不发生血清转化，或出现HBeAg(-)／抗-HBe( )，但HBV—DNA定量检测仍持续阳性患者与nt1896、nt1814、nt1762、nt1764位点突变有关；拉米夫定治疗后，HBV—DNA先下降或转阴，后又再度反弹患者与aa528、aa552变异(即YMDD变异)造成拉米夫定耐药有关；拉米夫定治疗52周以上的部分患者易发生YMDD变异(26．4％)；在慢性乙肝患者中nt1896位点变异较普遍(68．5％)；慢性重症肝炎、肝硬化失代偿、原发性肝癌与nt1896、nt1762、nt1764位点突变亦有关。结论 HBV基因变异可加重患者病情，影响抗病毒治疗效果。临床上通过对乙肝患者进行HBV常见变异位点进行检测，对判断疾病预后，调整抗病毒治疗方案具有一定的参考价值。     

HBV携带结核患者抗结核治疗中肝功能变化的临床分析

目的研究乙肝病毒携带结核患者抗结核治疗对肝功能的影响。方法选择我院住院的活动性肺结核患者338例,其中乙肝病毒携带肺结核患者36例,无乙肝病毒携带肺结核患者302例,对抗结核治疗中肝功能变化进行回顾性分析。结果HBV携带结核患者有30.6%出现肝损害,而对照组只有15.9%。HBV阳性组在治疗前ALT分层统计,A组(男≤30U/L,女19≤U/L)与B组(男31～40U/L,女20～40U/L),抗结核治疗后发生肝损害分别为24.1%、57.1%。A、B两组有显著性差异。结论乙肝病毒携带结核患者抗结核治疗易出现肝损害,肝功能ALT正常值上限(ULN)采用男30U/L,女19U/L较目前男女均为40U/L更为安全可靠。     

Development of transient autoimmune hepatitis during interferon treatment of chronic hepatitis B

Summary A 42-year-old man was treated with interferon- for chronic hepatitis B; during the fourth week of treatment he developed an exacerbation of liver disease, and nuclear and smooth muscle autoantibodies, which were previously negative, were detected in very high titers. After discontinuation of interferon therapy, ALT values subsided promptly and autoantibodies disappeared within a few months. This sequence of events strongly suggests a direct relationship between IFN treatment and a self-limited hepatitis with autoimmune markers in this case.     

乙型肝炎肝衰竭的抗病毒治疗

我国2006年《肝衰竭诊疗指南》根据病理组织学特征和病情发展速度,将肝衰竭分为急性肝衰竭(acute liver failure,ALF)、亚急性肝衰竭(subacute liver failure,SALF),慢加急性肝衰竭( acute - on - chronic liver failure,ACLF)以及慢性肝衰竭[1].在我国,感染是导致肝衰竭的主要因素,其中HBV感染导致的慢性乙型肝炎急性炎症活动是主要原因.我们回顾性分析了2002至2006年来自北方十三个省市自治区1977例肝衰竭病因构成及变化趋势,HBV感染占所有肝衰竭的82.8％[2].我国大部分HBV感染相关性肝衰竭以内科综合治疗为主,包括支持、免疫调节和防治并发症等.由于肝衰竭极为复杂的病理生理过程和临床症候群,缺乏特异性治疗手段,病死率居高不下.此类患者体内往往存在高水平的HBVDNA,因此近年来对于应用抗病毒治疗提高本病的生存率进行了有意义的临床探索.     

Acute liver failure caused by concurrent autoimmune hepatitis and hepatitis B in a 16-year old girl

A 16 year-old girl was admitted to hospital because of fatigue and somnolence, nausea, epistaxis and jaundice. Physical examination revealed jaundice, an enlarged liver and tenderness of upper right abdomen. Laboratory tests revealed an increased level of acute liver failure, bilirubin, bile acids, GGTP and a decreased prothrombin ratio, with elevated gamma-globulin and IgG levels, and the presence of anti-mitochondrial M2 antibodies and HBV infection markers. The patient was diagnosed with liver failure resulting from chronic hepatitis B with an autoimmune component. The treatment consisted of steroids, azathioprine, vitamin K, low-protein diet and lactulose enemas. After undergoing a molecular test (HBV DNA 3.23 × 10(5) IU/mL and mutations I 204 and I 80), the treatment was modified by adding entecavir. After one month the patient was discharged in good clinical condition, with the recommendation of continued entecavir, prednisone and azathioprine. In subsequent months, no clinical deterioration or abnormal biochemical liver function test results were found, despite the discontinuation of immunosuppressive therapy after 10 mo. The patient continues entecavir therapy.     

Clinical outcomes of chronic hepatitis B patients with persistently detectable serum hepatitis B virus DNA during lamivudine therapy

BACKGROUND AND AIM: A small proportion of chronic hepatitis B patients have persistently detectable serum hepatitis B virus (HBV) DNA despite lamivudine therapy. The incidence and clinical outcomes of patients who persistently have detectable serum HBV-DNA during lamivudine therapy was investigated. METHOD: We enrolled 221 chronic hepatitis B patients who underwent lamivudine therapy for more than 6 months. Among them, 180 were HBeAg positive. Serum HBV-DNA, HBeAg, anti-HBe and alanine aminotransferase (ALT) levels were serially monitored. The study groups were defined, using a hybridization assay, as patients with reductions in serum HBV-DNA below the detectable level (group I) or patients with persistently detectable serum HBV-DNA (group II) during the initial 6 months of lamivudine therapy. RESULTS: The incidence of patients who had persistently detectable HBV-DNA was 7.7%. After the first year, the rates of viral breakthrough, HBeAg loss and serum ALT normalization of group I versus group II were 21% versus 63%, 38% versus 0%, and 71% versus 28%, respectively (P < 0.001). The log(10) reduction of serum HBV-DNA at 6 months was -4.58 log(10) for group I and -1.97 log(10) for group II (P < 0.001, bDNA assay). There were no pretreatment lamivudine-resistant mutants in group II. CONCLUSION: Lamivudine had little effect on serum HBV-DNA suppression, viral breakthrough suppression and rate of HBeAg loss and ALT normalization in chronic hepatitis B patients with persistently detectable serum HBV-DNA during the initial 6 months of therapy. Early termination of lamivudine therapy is advocated for these patients.     

肺结核合并慢性乙型肝炎患者治疗经验*

目的 探讨有效抗HBV治疗对肺结核合并慢性乙型肝炎患者抗结核治疗过程中肝损伤的防治效果。方法 2012年1月至2014年12月我院收治的210例肺结核合并慢性乙型肝炎患者被随机分为两组。在抗结核治疗过程中, 109例接受恩替卡韦或拉米夫定抗病毒治疗,另101例未行抗病毒治疗,比较两组肝损伤和终止抗结核治疗发生率以及抗结核治疗前后肝功能和血清HBV DNA的变化情况。结果 抗病毒组肝损伤和终止抗结核发生率分别为2.8%和2.8%,均显著低于未抗病毒组的57.4%和36.6%（P＜0.01）;抗病毒组患者治疗前血清ALT和AST分别为（33.1±6.5） U/L和（27.2±5.2） U/L,血清HBV DNA为（7.0±0.9） lgcopies/ml,治疗后血清ALT和AST无明显变化,血清HBV DNA阴转为（2.6±1.0） lgcopies/ml,而未抗病毒组患者血清ALT和AST略有上升,血清HBV DNA无变化。结论 在HBV DNA阳性的肺结核患者中,通过有效的抗病毒治疗,能降低血清病毒载量,减少抗痨过程中肝损伤的发生率,使抗结核治疗方案能顺利完成。     

拉米夫定治疗慢性乙型肝炎发生YMDD变异的研究

目的探讨拉米夫定治疗慢性乙型肝炎（CHB）发生YMDD变异的临床意义。方法分别用荧光定量PCR、ELISA检测72例用拉米夫定治疗的CHB患者治疗前（0个月）、治疗中（9、12、18个月）YMDD变异的情况、HBVDNA定量水平、两对半等指标。结果72例CHB患者中,拉米夫定治疗前未检查出YMDD变异,治疗9、12、18个月分别检出YMDD变异8例（11.1%）,17例（23.6%）,28例（38.9%）,随治疗时间的延长,YMDD变异率升高（P〈0.05）。另外用药前HBVDNA定量〉108copies/ml与HBVDNA定量〈108copies/ml相比YMDD变异率显著升高（P〈0.005）。HBeAg阳性组与HBeAg阴性组的患者在不同治疗时间YMDD变异率,差异无显著性（P〉0.05）。结论YMDD变异的发生随治疗时间的延长而增加。血清病毒载量可作为应用拉米夫定治疗YMDD变异产生的早期预测指标。     

Noninvasive assessment of liver damage in chronic hepatitis B

AIM:To evaluate the efficacy of the aspartate aminotransferase/platelet ratio index(APRI)and neutrophillymphocyte(N/L)ratio to predict liver damage in chronic hepatitis B(CHB).METHODS:We analyzed 89 patients diagnosed with CHB by percutaneous liver biopsy and 43 healthy subjects.Liver biopsy materials were stained with hematoxylin-eosin and Masson’s trichrome.Patients’fibrosis scores and histological activity index(HAI)were calculated according to the Ishak scoring system.Fibrosis score was recognized as follows:F0-1 No/early-stage fibrosis,F2-6 significant fibrosis,F0-4 non-cirrhotic and F5-6 cirrhotic.Significant liver fibrosis was defined as an Ishak score of≥2.APRI and N/L ratio calculation was made by blood test results.RESULTS:The hepatitis B and control group showed no difference in N/L ratios while there was a significant difference in terms of APRI scores(P<0.001).Multiple logistic regression analysis revealed that the only independent predictive factor for liver fibrosis in CHB was platelet count.APRI score was significantly higher in cirrhotic patients than in non-cirrhotic patients.However,this significance was not confirmed by multiple logistic regression analysis.The optimum APRI score cut-off point to identify patients with cirrhosis was 1.01with sensitivity,specificity,positive predictive value and negative predictive value of 62%(36%-86%),74%(62%-83%),29%(13%-49%)and 92%(82%-97%),respectively.In addition,correlation analyses revealed that N/L ratio has a negative and significant relationship with HAI(r=-0.218,P=0.041).CONCLUSION:N/L ratio was negatively correlated with HAI.APRI score may be useful to exclude cirrhosis in CHB patients.     

肝病治疗仪治疗慢性乙型肝炎患者的护理体会

目的 总结肝病治疗仪治疗慢性乙型肝炎患者的护理措施和体会.方法 回顾性分析196例慢性乙型肝炎患者使用肝病治疗仪的护理过程,总结护理经验.结果 患者对肝病治疗仪的认知度、穴位的准确定位、脉冲治疗的强度、皮肤及心理护理是护理要点.结论 良好的护理有助于提高患者的舒适度及依从性,减少不良反应.