HBsAg与抗-HBs同时阳性的慢性乙型肝炎患者临床特点分析

目的分析HBsAg与抗-HBs同时阳性的现象及其临床特点,并探讨其产生的原因。方法收集2011年2月-2014年2月东南大学附属第二医院体检者2260例,其中被诊断为慢性乙型肝炎的患者830例。采用化学发光微粒子免疫分析法筛选HBsAg与抗-HBs同时阳性的患者188例,分为HBeAg阳性组(n=101)和HBeAg阴性组(n=87)。同时选取200例HBsAg阳性、抗-HBs阴性者作为对照,其中HBeAg阳性组80例,HBeAg阴性组120例。检测HBV血清学标志物、肝功能、病毒载量并结合临床进行分析。计数资料组间比较采用χ2检验。结果 HBV血清学标志物在HBsAg与抗-HBs双阳性情况下共有5种模式,其中以HBsAg、抗-HBs、HBeAg及抗-HBc阳性,且抗-HBe阴性多见,占47.9%(90/188),肝功能指标总异常率为69.1%(130/188),HBV DNA总阳性率为56.9%(107/188)。HBeAg阳性的2组HBV DNA均存在高水平复制,其中HBsAg与抗-HBs双阳性组HBV DNA阳性率与对照组比较,差异无统计学意义(χ2=2.632,P0.05);HBeAg阴性组中,HBsAg与抗-HBs双阳性组HBV DNA定量1×105IU/ml的比例与对照组比较,差异有统计学意义(χ2=10.740,P0.05)。对HBV S区进行测序分析发现,测序的80例HBsAg与抗-HBs双阳性患者中有27例患者的HBV S区发生变异,突变率33.7%,且S区变异位点主要有P29L、S61L、P62L、I126T/S、Q129N、M133K、F134L、G145R/K、L175S和L186H等。结论 HBsAg与抗-HBs同时阳性者在乙型肝炎患者中有一定比例,其主要原因可能是病毒株变异所致。这种情况并不代表疾病好转,且抗-HBs出现并不一定能完全有效清除HBsAg,病毒DNA往往存在持续复制,需引起重视。     

隐匿性乙型肝炎病毒感染者血清表面抗体性质鉴定

目的 了解隐匿性HBV感染者抗-HBs的特性及其与HBsAg的结合能力.方法 对2例抗-HBs阳性的隐匿性HBV感染者进行长期随访,使用多种试剂盒对患者血清进行多次HBsAg检测,利用不同血清型HBsAg对患者血清进行中和反应,了解血清中抗体亚型情况.PCR扩增S基因构建真核表达质粒,分析S基因变异情况,并将质粒转染HepG2细胞,取培养上清液及转染细胞分别混合进行HBsAg检测.使用患者血清及抗-HBs阳性血清(对照组)对部分HBsAg阳性克隆上清液进行中和反应.不同组间数据比较采用t检验.结果 多种试剂盒进行的多次检测结果均表明患者血清HBsAg为阴性;HBsAg的3种不同血清型(adr、adw、ay)均能够中和患者血清中大部分抗-HBs(82.1%～100.0%).S基因序列分析表明核苷酸同源性和氨基酸同源性分别为95.13%～97.79%和92.04%～95.58%;培养上清液和转染细胞裂解液中HBsAg定量分别为对照组的48.1%和59.3%,上清液/细胞裂解液比值分别为0.85和0.38.中和试验结果显示转染上清液中HBsAg定量较混合前有所降低,但是仍然可以检测到,而对照组检测不到HBsAg,差异均有统计学意义(F值分别为353.6和645.2,P值均<0.01).结论 抗-HBs阳性隐匿性HBV感染者体内HBsAg的抗原性及分泌能力有所下降,抗HBs主要针对不同血清型HBsAg的共同表位,但可能与疫苗注射产生的抗-HBs有所不同.

Abstract：

Objective To investigate the properties of HBsAb in occult hepatitis B virus infection and its affinity to different serotypes of hepatitis B virus surface antigen (HBsAg). Methods Long-term follow-up was conducted in 2 HBsAb positive patients with occult hepatitis B virus infection. HBsAg was detected using multiple diagnostic kits and the HBsAb subtype was determined by performing neutralization experiments with different serotypes of HBsAg. The viral S gene was PCR-amplified and mutation analysis was conducted. Plasmids expressing HBsAgs were constructed by inserting these PCR products into an eukaryotic expression vector and were then transfected into HepG2 cells. The cell culture supernatant and cellular extracts were detected for HBsAg respectively. Neutralization experiments were carried out in the cell culture supernatant from HBsAg plasmids transfected HepG2 cells and serum samples from these patients and others who had been confirmed to be positive for HBsAb. Results Multiple tests using various diagnostic kits showed that the 2 patients were negative for HBsAg and the three different serotypes of HBsAg (adr, adw, ay) could neutralize 82.1%-100% of HBsAb existed in the 2 patients. Sequence analysis of S gene cloned from these patients revealed that the homology to reference strain were 95.13%-97.79% and 92.04%-95.58% respectively at the nucleotide and amino acid levels. Quantitation of HBsAg showed that the expression levels of HBsAg from the two patients were 41.1% and 22.6% respectively of that of control HBsAg in cell culture supernatant and 48.1% and 59.3% respectively in cellular extract, and the supernatant/cell lysate ratios were 0.85 and 0.38 respectively. In neutralization experiments, HBsAg could be totally absorbed by control serum, whereas could only be partially neutralized by HBsAbs from the two patients (F = 353.6 and 645.2, P < 0.01). Conclusion Both the antigenicity and the ability of HBsAg secreted outside of the cells are decresed in these HBsAb-positive patients with occult HBV infection. The HBsAbs are mainly specific for common epitopes among different serotypes of HBsAg and are probably different as compared with those produced by vaccine inoculation.     

HBsAg与抗-HBs同时阳性慢性乙肝患者HBV基因全序列分析

目的 报告HBsAg与抗-HBs同时阳性慢性乙肝患者基因序列变化特点.方法 对三例HBsAg与抗-HBs同时阳性慢性乙肝患者血清中HBV DNA基因全序列进行PCR扩增、测序,并对测序结果及S区氨基酸进行分析.结果 测序结果发现三例患者血清中HBV S区氨基酸均发生替换突变,并且,三例患者中HBV DNA发生碱基替换的位点大部分相同,且替换后碱基基本相同.结论 HBsAg与抗-HBs同时阳性慢性乙型肝炎患者常发生S区氨基酸序列突变,双阳现象的出现亦可能与S区外其他位点碱基突变有关.     

HBsAg和HBsAb同时阳性慢性HBV感染者血清病毒PreS/S区基因序列分析及临床意义探讨

目的：分析HBsAg和HBsAb同时阳性慢性HBV感染者的血清病毒PreS/S区基因序列,探讨其临床意义。方法：收集HBsAg和HBsAb同时阳性慢性HBV感染者32例,其中HBV DNA阳性者12例（实验组）,其余20例为HBV DNA阴性。另外选取HBsAg阳性、HBsAb阴性和HBV DNA阳性的慢性HBV感染者12例（对照组）。采用聚合酶链反应（PCR）法体外扩增两组患者HBV PreS/S基因序列并测序分析,比较两组间PreS/S基因变异情况,结合临床资料探讨其临床意义。结果：实验组与对照组在性别、年龄、HBeAg阳性率、HBsAg滴度及HBV DNA水平上差异均无显著性意义（P〉0.05）。两组基因型分布亦相似（P〉0.05）。实验组与对照组在PreS1区、PreS2区、S区、MHR（主要亲水）区及＂a＂表位区各区域的核苷酸替换率相当（P〉0.05）。实验组中1例患者的PreS区有一长约144bp的片段缺失,位于PreS/S区nt285~428位（PreS1区末端及PreS2区起始部）。结论：HBsAg和HBsAb同时阳性的现象与PreS/S区基因突变无明显的相关性,HBsAb的出现对HBsAg和HBsAb同时阳性且HBV DNA亦阳性的患者不具有保护作用。     

人类免疫缺陷病毒感染者合并隐匿性乙型肝炎病毒感染的现状调查

目的 调查分析上海地区HIV感染者中隐匿性HBV感染的流行现状.方法 对上海市公共卫生临床中心就诊的HIV感染者在尚未接受抗病毒治疗前采集血标本,检测HBsAg、抗-HBs、HBeAg、抗-HBe、抗-HBc,抗-HCV,CD4+T细胞计数,使用巢式PCR法检测HBV S区.结果 105例(男92例,女13例)HBsAg阴性的HIV感染者中32例(男27例,女5例)HBV DNA阳性;16～30岁年龄组22例,其中5例HBV DNA阳性,31～49岁年龄组44例,其中15例HBV DNA阳性,50～75岁年龄组39例,其中12例HBV DNA阳性;32例中有27例至少一项HBV血清学标志物阳性,5例均阴性.47例合并HCV感染者中有14例HBV DNA阳性,阳性率29.8%;58例未合并HCV感染的HIV感染者中18例HBV DNA阳性,阳性率为31.0%.CD4+T细胞计数平均值145.1个/μ(4～623个/μ1),75例CD4+T细胞<200个/μ1的患者中有26例HBV DNA阳性,约占34.7%,30例CD4+T细胞>200/μ1患者中有6例HBV DNA阳性,阳性率为20.0%.以上各项之间两两相比差异均无统计学意义.结论 HIV感染者中存在隐匿性HBV感染,且与HIV感染者性别、年龄、HBV标志物、是否合并HCV感染及CD4+T细胞计数无明显相关.     

B和C基因型乙型肝炎病毒对阿德福韦酯治疗的病毒学应答比较

目的 阐明不同基因型HBV对阿德福韦酯治疗反应是否存在差异.方法 首先利用型特异引物PCR法结合型特异核苷酸分析法检测HBV基因型,然后根据基因型对阿德福韦酯Ⅲ期临床资料进行分析及统计学处理(计量资料用t检验,计数资料用卡方检验).结果 177例临床标本检出B基因型HBV感染者102例,C基因型感染者65例,B+C混合型感染者6例,B+D混合型感染者4例.治疗第12、24周时,B基因型组和C基因型组血清HBV DNA下降均值分别为2.2log10>拷贝/ml、2.1log10拷贝/ml和2.7log10拷贝/ml、2.4log10拷贝/ml,两组差异均无统计学意义(P>0.05),第48周时两组HBV DNA分别下降3.6log10拷贝/ml和3.1log10拷贝/ml,差异有统计学意义(P<0.05).治疗结束时(48周)B基因型组和c基因型组分别有43例(42.2%)和22例(33.8%)出现血清HBV DNA转阴,差异有统计学意义(P<0.05);两组患者HBeAg阴转率抗-Hbe血清转换率分别为30.4%、29.2%和21.6%、20.0%,差异无统计学意义(P>0.05).两组患者血清ALT复常率在治疗第12、24、36周和48周时分别为35.3%、33.9%,51.0%、53.9%,63.4%、61.5%和83.3%、81.5%,各时间段两组ALT复常率差异均无统计学意义(P>0.05).结论 阿德福韦酯治疗慢性乙型肝炎48周时,部分病毒学指标(如血清HBV DNA下降均值和HBV DNA阴转率)B基因型优于C基因型HBV感染者.但由于阿德福韦酯起效较慢,抑制病毒作用相对较弱,有必要延长治疗时间进一步证实这一现象.     

乙型肝炎相关性肝衰竭患者HBV DNA低水平复制及特异性抗体表达的临床意义

目的探讨乙型肝炎相关性肝衰竭患者血清HBV DNA低水平复制及HBV特异性抗体表达的相关因素及临床意义。方法收集2008年6月至2013年12月于天津市第二人民医院住院治疗的391例乙型肝炎相关性肝衰竭患者及394例慢性乙型肝炎患者的病历资料。比较乙型肝炎相关性肝衰竭与慢性乙型肝炎患者HBV DNA表达的不同及影响因素分析。根据HBV血清学标志物(HBV M)特异性表达的不同将肝衰竭患者分为特异性抗体阳性(指抗-HBs、抗-HBe和抗-HBc同时阳性)和特异性抗体阴性(无抗-HBs、抗-HBe和抗-HBc同时阳性)2组,分析2组患者HBV DNA水平的变化和生存情况。组间比较采用独立样本t检验或MannWhitney秩和检验,计数资料比较采用χ2检验。结果乙型肝炎相关性肝衰竭患者HBV DNA水平低于慢性乙型肝炎组,差异有统计学意义(Z=-16.469,P0.05);HBeAg阳性和阴性的肝衰竭患者HBV DNA水平均低于相应的慢性乙型肝炎患者,差异有统计学意义(Z分别为-11.665和-12.853,P0.05)。在391肝衰竭病例中,HBV特异性抗体阳性组29例(7.42%),死亡25例(86.21%),HBV特异性抗体阴性组362例(92.58%),死亡157例(43.37%),2组病死率差异有统计学意义(P0.05)。特异性抗体阳性组患者HBV DNA水平明显低于特异性抗体阴性组,差异有统计学意义(Z=-3.594,P0.05)。2组HBeAg阴性患者HBV DNA水平均低于HBeAg阳性患者,差异有统计学意义(Z分别为7.427和7.513,P0.05)。结论 HBV M表达形式及机体免疫状态的动态变化在乙型肝炎相关性肝衰竭的发生发展过程中起着一定作用,HBV DNA低水平复制系机体处于免疫清除期所致,而同时伴抗-HBs、抗-HBe、抗-HBc 3个抗体同时阳性则提示机体对HBV的超强免疫反应,致使病情恶化、发展迅速,病死率高。     

HBV感染恢复期血清标志物与肝细胞HBV cccDNA检测对照

目的:了解肝组织乙肝病毒共价闭合环状脱氧核糖核酸(HBV cccDNA)与血清HBV复制指标的关系,以探索判定抗HBV的疗程终结点的观察方法。方法:既往HBV感染者、乙型肝炎肝硬化肝癌及慢性乙型肝炎(CHB)患者各13例,将血清HBV DNA、HBV-M及肝组织HBV cccDNA检测结果进行对照。结果:肝硬化肝癌及CHB患者抗-HBe阳性分别为12例和9例,血HBV DNA阳性分别为6例和8例,肝细胞HBV cccDNA均阳性;既往HBV感染13例中,HBsAg阴性,抗-HBs和/或抗HBc阳性各7和6例,有3例肝细胞中HBV cccDNA阳性。抗-HBs阳性的7例肝细胞HBV cccDNA阴性,抗-HBe阳性及抗HBs合并抗-HBe阳性者,肝细胞HBV cccDNA分别为105拷贝/ml和103拷贝/ml,与抗-HBs阳性组对照,t=4.5、4.0(P均<0.01),差异有非常显著性意义。CHB患者核苷类治疗后全应答,肝组织HBV cccDNA仍均为阳性。结论:抗-HBs阳性HBV感染后恢复期血清,肝组织HBV cccDNA阳性比率明显低于CHB抗HBe阳性HBV DNA阴性病例。抗病毒治疗CHB的终点,应是血清抗-HBs阳性的出现。     

未抗病毒治疗人类免疫缺陷病毒感染者隐匿性乙型肝炎的调查及其临床特点

目的 观察未经抗病毒治疗(ART)的人类免疫缺陷病毒(HIV)感染者和普通人群隐匿性乙型肝炎流行状况,评估HIV感染者合并隐匿性乙型肝炎的临床特点.方法 通过酶联免疫分析法检测未经ART治疗的HIV感染者和普通人群血浆HBsAg、抗-HBs、HBeAg、抗-HBe和抗-HBc水平,筛查出HBsAg阴性的HIV感染者(感染组)249例,健康体检者HBsAg阴性者121例(健康组),再采用罗氏COBASAmpliPrep/COBAS TaqManHBVTest,version2.0试剂盒检测外周血HBV DNA水平.统计分析用STATA 10软件处理本实验各组数据.用Fisher's精确概率检验、秩和检验.结果 感染组HBV DNA阳性者24例,隐匿性乙型肝炎占9.7％;健康组HBV DNA阳性者4例,隐匿性乙型肝炎占3.3％,两组比较,P=0.035,差异有统计学意义.感染组24例HBVDNA阳性者,HBV DNA载量最低者血中能测到,但在检测值水平以下,(即＜20 IU/ml),最高者3.22×105 IU/ml.大于100 IU/ml占37.5％(9/24),20 ～ 99 IU/ml占16.7％ (4/24),＜20IU/ml,但可测出HBV DNA占45.8％ (11/24).HIV感染者抗-HBc(+)/抗-HBs(+)组、抗-HBc(+)/抗-HBs(-)组、抗-HBc(-)/抗-HBs(+)组、抗-HBc(-)/抗-HBs(-)组DNA阳性率分别为7.3％ (8/110),20.8％ (11/53),14.3％ (3/21),3.1％(2/64),抗-HBc(+)/抗-HBs(-)组分别与抗-HBc(+)/抗-HBs(+)组、抗-HBc(-)/抗-HBs(-)组两组比较,P值分别为0.018和0.003,差异有统计学意义.四组间HBV DNA病毒载量比较,P=0.805,差异无统计学意义.感染组HBV DNA(+)组与HBV DNA(-)组比较,CD4计数(Z=1.902,P=0.0586)和ALT水平(Z=1.401,P=0.1611)差异无统计学意义.结论 在未经ART治疗HIV感染者中,隐匿性乙型肝炎高于普通人群,HIV感染者抗-HBc(+)/抗-HBs(-)组隐匿性乙型肝炎最高.     

替比夫定对乙型肝炎病毒转基因鼠孕期安全性的实验研究

目的 探讨HBV转基因鼠孕期应用抗病毒药替比夫定对降低HBV载量、HBsAg水平的有效性以及对母、胎鼠的安全性.方法 33只HBV转基因雌鼠均分为3组.交配当天至分娩当天,HBV Tg对照组每天喂0.9%氯化钠溶液,HBV Tg-L与HBV Tg-H实验组分别予替比夫定600和1200 mg·kg~(-1)·d~(-1)灌胃.普通雌鼠11只为健康对照组,予替比夫定600 mg·kg~(-1)·d~(-1)灌胃.交配当天、分娩当天采血.ELISA法测HBsAg,荧光定量PCR法测HBV DNA.观察4组雌鼠的妊娠生育状况及子鼠的生长发育情况,子鼠28 d时检测HBsAg、HBV DNA.数据行方差分析、t检验和χ~2检验.结果 HBV Tg对照组雌鼠用药前后血清HBsAg水平差异无统计学意义(t=0.34,P>0.05),HBV Tg-L和HBV Tg-H实验组雌鼠血清HBsAg分别为(187.39±23.18)μg/L比(160.50±27.69)μg/L,(190.48±22.43)μg/L比(161.89±21.23)μg/L(t=2.91,t=3.16;均P<0.05),用药前后血清HBV DNA水平差异无统计意义(P>0.05).HBV Tg对照组、HBV Tg-L与HBV Tg-H实验组子鼠血清HBV DNA水平分别为(11.22±1.08)、(8.38±1.80)和(8.97±1.86)lg拷贝/mL(F=4.34,P<0.05),HBsAg分别为(93.03±18.37)、(9.56±4.39)和(9.27±2.69)μg/L(F=18.11,P<0.05).各组子鼠的生长发育指标差异均无统计学意义(P>0.05).结论 孕期应用替比夫定对母鼠子鼠的安全性无影响,由于HBV转基因鼠的种类、孕期短等原因,雌鼠血清HBsAg下降明显,对HBV DNA水平影响较小.     

HBsAg和HBsAb双阳性检测结果的初步分析

目的对临床检测中少见的HBsAg和HBsAb双阳性结果进行分析,寻找可能的产生原因。方法对3家医院初筛HBsAg和HBsAb双阳性的81份血标本进行同种和不同种试剂盒复检,并检测HBsAg145位氨基酸变异（G145R变异）、HBVDNA基因型和血清型分析。结果81份双阳性标本经复检有30例（37％）仍然为双阳性;对30例复检双阳性标本应用不同试剂盒再次检测,HBsAg／HBsAb仍为双阳性者18例（22．2％）;18例双阳性标本G145R检测全部为阴性;其中8例HBV DNA阳性血清的基因型分布为B型2例和C型6例,血清型分布为adw2例、adr5例和ayr1例,与9份对照血清的检测结果比无显著性差异。结论HBsAg和HBsAb双阳性检测结果大多数与操作或试剂的质量有关,少数可能为S基因变异或不同血清型的再次感染等有关。     

Sequence analysis of the S gene region in HBV DNA from patients positive for both HBsAg and HBsAb tests

Aims: To study the characteristics of mutation in the amino acids coded by the S gene region in the HBV DNA sequence and to comprehensively explore and analyze the cause of the double positive result phenomena in both HBsAg and HBsAb tests. Methods: Specimens collected from 43 cases of chronic hepatitis B patients with positive results for both HBsAg and HBsAb tests were used as the experimental group; specimens collected from 43 cases randomly picked from all patients with chronic hepatitis B with a single positive result for HBsAg test were used as the control group. In HBV DNA, the S gene region was amplified and sequenced. Amino acid sequences were grouped, and mutations were analyzed based on the sequencing results. Results: The patients were infected with HBV of the genotype B and C and those who with genotype C show more mutations than genotype B carriers. Compared with the control group, the experimental group had a marked increase in S gene amino acid mutations; a higher amino acid mutation rate was observed in the first loop (aa124–137) of the a‐determinant (aa124–147) and there was a statistical difference (genotype B: 2.68% vs. 0.00%, P = 0.041; genotype C: 7.14% vs. 2.01%, P < 0.001). Conclusion: The first loop in a‐determinant of S gene sequence possesses a large numbers of mutated amino acids, leading to changes of antigenicity and simultaneous positive results in both HBsAg and HBsAb tests finally.     

未经治疗的慢性乙型肝炎患者乙型肝炎病毒耐药变异、基因型和血清型研究

目的 研究未经核苷(酸)类似物(NA)治疗的慢性乙型肝炎患者HBV耐药变异、基因型、基因亚型和血清型特点.方法 从北京大学附属医院收集97例未经NA治疗的慢性乙型肝炎患者血清,用半巢式聚合酶链反应-直接测序法获得HBV全长逆转录酶区序列,用生物信息学技术筛查该区内11个经典耐药变异位点并鉴定基因型、基因亚型和血清型.用统计分析软件SPSS11.0进行t检验和χ~2检验. 结果 HBV在11个经典耐药变异位点上均为野生型氨基酸;B基因型和C基因型分别占36.1%(35/97)和63.9%(62/97),前者均属B2亚型,后者C2亚型占91.9%(57/62),C1亚型占6.5%(4/62),1例未能分出亚型.已知出生地的患者中,71.9%(23/32) B基因型感染者出生于我国南方地区,81.6%(40/49) C基因型感染者出生于北方地区,基因型地域分布特点明显,χ~2=23.19,P<0.01.血清型为adr者占60.8%(59/97),与C基因型相关;为adw者占38.1%(37/97),与B基因型相关,χ~2=87.83,P<0.01.结论 未经NA治疗的慢性乙型肝炎患者体内野毒株为优势株,其基因型、基因亚型和血清型与患者出生地有关.     

Molecular epidemiological study of hepatitis B virus in Thailand based on the analysis of pre-S and S genes.

Aims: This study was undertaken to determine the prevalence and characteristics of hepatitis B virus (HBV) genotypes, antigen subtypes, "a" determinant variants and pre-S gene mutations circulating on a large scale in Thailand. Methods: The sequences of the Pre-S1, Pre-S2 and S regions were determined in serum samples of 147 HBsAg and HBV DNA-positive subjects who had been enrolled from the nationwide seroepidemiological survey conducted on 6213 individuals in 2004. Results: The results showed that genotypes C, B and A accounted for 87.1%, 11.6% and 1.3%, respectively. The distribution of the HBV antigen subtypes was: adr (84.4%), adw (14.2%) and ayw (1.4%). Regarding the "a" determinant, 2/43 (4.65%) and 2/104 (1.92%) samples of vaccinated and non-vaccinated subjects, respectively, displayed mutations, all ofwhich were Thr126Asn. Sequencing analysis showed the pre-S mutations in 14 (9.5%) samples, with pre-S2 deletion as the most common mutant (4.1%) followed by pre-S2 start codon mutation (2.9%), both pre-S2 deletion and start codon mutation (2.0%), and pre-S1 deletion (0.7%). The pre-S mutations were associated with older age and higher mean serum HBsAg level. Conclusion: This study demonstrated that HBV genotype/subtype C/adr and B/adw were the predominant strains circulating in Thailand. The "a" determinant variants seemed to be uncommon, and might not be attributed to vaccine-induced mutation.     

HBsAg阳性母亲所生婴儿的母婴阻断及全程接种乙型肝炎疫苗后免疫应答状态

目的 了解HBsAg阳性母亲所生婴儿的母婴阻断及全程接种乙型肝炎疫苗后免疫应答状态及变化规律.方法 对249例HBsAg阳性母亲的新生儿予以联合母婴阻断措施,并全程接种乙型肝炎疫苗,用微粒化学发光法跟踪测定婴儿生后7、12、24、36个月的HBsAg和抗-HBs水平.组间比较采用卡方检验.结果 HBsAg阳性母亲所生婴儿母婴阻断后不同时间免疫应答状态不同,7月龄婴儿无应答率为8.0%(20/249),低应答率为11.7%(29/249),强应答率为80.3%(200/249);12月龄婴儿无应答率为10.8%(13/120),低应答率为26.7%(32/120),强应答率为62.5%(75/120);24月龄婴儿无应答率14.8%(4/27),低应答率为33.3%(9/27),强应答率为51.9%(14/27),36月龄婴儿无应答率为14.3%(1/7),低应答率为28.6%(2/7),强应答率为57.1%(4/7);7月龄组与其他月龄组同等应答状态间比较,差异有统计学意义(x2=21.98,P＜0.01).强应答组婴幼儿抗-HBs效价出生7个月后出现逐渐下降的趋势,效价越高,其下降的例数越少,下降出现的时间越晚.抗-HBs效价＞1000 mIU/mL时,在36个月内下降比率为57.6%(19/33),下降高峰为24个月(57.9%,11/19);抗-HBs效价为100～1000 mIU/mL时,在36个月内下降比率为73.8%(31/42),下降高峰为12个月(54.8%,17/31).HBsAg阳性婴儿7月龄多表现为无应答状态,占全部无应答婴儿的70%(14/20,x2=128.61,P＜0.01),99%(189/191)HBsAg阴性婴儿多为强应答.HBeAg同时阳性母亲的婴儿无应答率有高于HBeAg阴性母亲婴儿的趋势,但差异无统计学意义(9.1%比5.5%,x2=0.24,P＞0.05).结论 HBsAg阳性母亲新生婴儿的母婴阻断及全程接种乙型肝炎疫苗后不同时间免疫应答状态不同,且呈动态变化;无应答状态多见于HBsAg阳性的免疫失败婴儿;HBsAg阴性婴儿大多呈强应答;HBeAg同时阳性的母亲婴儿更易呈低应答.建议完善母婴阻断后管理流程,特别是生后7个月～2年的积极随访监测.     

HBsAg/HBsAb双阳性慢性乙型肝炎患者HBV S基因免疫逃逸相关变异分析

目的分析HBsAg/HBsAb双阳性慢性乙型肝炎患者HBV S基因主要亲水区免疫逃逸相关位点变异特点。方法收集89例HBsAg/HBsAb双阳性和148例HBsAg单阳性的慢性乙型肝炎患者血清及临床资料,提取患者血清HBV DNA,扩增患者HBV S基因并进行测序,应用DNASTAR Lasergene Meg Align软件对主要亲水区已有文献报道的46个免疫逃逸相关位点及新增N-糖基化变异进行比对分析。结果 2组患者在年龄、ALT、TBIL、HBV DNA载量和HBe Ag阳性率方面差异均无统计学意义(P均0.05)。HBsAg/HBsAb双阳性患者HBV S基因主要亲水区变异的总检出率为31.46%,明显高于HBsAg单阳性患者的18.92%(P0.05),其中s L110I/S、s T113N/S、s T131I/N/P和s S143L/M/T的变异检出率明显高于单阳性组;双阳性患者多位点联合变异检出率亦明显高于单阳性患者(20.22%vs.6.08%,P0.05)。双阳性患者新增N-糖基化变异检出率高于单阳性患者(7.87%vs.2.03%),差异具有统计学意义(P0.05)。结论 HBsAg/HBsAb双阳性患者比HBsAg单阳性患者的HBV S基因免疫逃逸相关变异种类更多,单位点和多位点联合变异检出率更高,并且新增N-糖基化变异检出率也更高,这些变异可能是引起慢性乙型肝炎患者HBsAg/HBsAb双阳性共存的驱动因素之一。     

Hepatitis B surface antigen disappearance and hepatitis B surface antigen subtype: a prospective, long-term, follow-up study of Japanese residents of Okinawa, Japan with chronic hepatitis B virus infection.

To determine the natural course of hepatitis B surface antigen (HBsAg) disappearance in chronic hepatitis B virus (HBV) infection and the factors related to its disappearance, 946 HBsAg carriers in Okinawa, Japan were prospectively followed for up to 19 years (mean = 9.2 years). The disappearance of HBsAg, as determined by radioimmunoassay (RIA), was observed in 62 (6.6%) and the overall annual disappearance rate was 0.79%/year. Its disappearance was more frequent in 60 (7.4%) of 815 serum samples negative for hepatitis B e antigen (HBeAg) by RIA at entry compared with only two (1.5%) of 131 serum samples that were HBeAg positive by RIA at entry (P < 0.05). Stepwise logistic regression analysis showed that age and HBsAg subtype were significantly associated with HBsAg disappearance (both P < 0.05), and that carriers with subtype adr (odds ratio = 2.87) had an increased probability of clearing HBsAg compared with carriers with subtype adw. Conversely, HBeAg disappearance was earlier in those with the adw subtype than in those with adr. Hepatitis B virus DNA was not detected by the polymerase chain reaction after HBsAg disappearance in any of the 62 from whom it had disappeared. The HBsAg titer, as measured by reverse passive hemagglutination, was related to the time to its disappearance; the higher the titer, the longer the time to disappearance. These findings suggest that HBeAg negativity, a more advanced age, and low titers of HBsAg are favorable factors for HBsAg disappearance in the natural course of chronic HBV infection. Moreover, HBsAg subtype adr was a predictive factor for HBsAg disappearance, whereas subtype adw was predictive of early HBeAg disappearance.     

慢性乙型肝炎病毒感染S区基因缺失及相关因素研究

目的 测定慢性乙型肝炎病毒(HBV)感染者HBV DNA全序列,分析S区基因缺失模式、频率及相关因素.方法 慢性HBV感染者59例,其中HBV携带7例,慢性肝炎31例,肝硬化10例,重型肝炎6例,原发性肝癌5例.结果 25.4%(15/59)慢性HBV感染者有s区基因缺失,未发现S基因缺失.Pre-S基因缺失均见于C基因型患者.Pre-S基因缺失患者中,20%(3/15)HBsAg、抗HBs共存,与无S区缺失者比较有明显差异(P<0.05).PreS基因缺失与病程(偏相关系数0.28,P=0.049)、抗病毒治疗(偏相关系数-0.451,P=0.036)有密切关系.结论 Pre-S基因缺失在基因C型、严重肝病及活动性HBV复制患者多见,可能与病程长及抗病毒治疗有关.Pre-S基因缺失可导致HBV免疫逃避或免疫治疗失败,可能是肝脏疾病发展的重要原因.     

拉米夫定治疗无良好应答患者乙型肝炎病毒P区突变与基因型的关系

目的 观察拉米夫定治疗后无良好应答的慢性乙型肝炎患者HBV P区变异情况与基因型的关系.方法 对631例拉米夫定治疗后无良好应答的慢性乙型肝炎患者进行研究.通过荧光定量PCR或核酸测序确定HBV基因型,直接测序观察P区突变,实时荧光定量PCR方法检测患者病毒载量,比较不同基因型患者的HBV DNA水平及HBV P区变异情况.计量资料采用成组设计资料t检验,计数资料采用x~2检验或Fisher精确检验.结果 631例慢性乙型肝炎患者中,B基因型HBV感染者272例,C基因型感染者359例,C基因型感染者患者年龄为(39.1±11.4)岁,明显大于B基因型感染患者的(33.7±9.7)岁(t=-6.55,P<0.01).C基因患者病毒载量为(5.96±1.22)log_(10)拷贝/ml,高于B基因型患者的(5.58±1.21)log_(10)拷贝/ml,t=-2.01,P<0.05.A181V/T变异在C基因型的发生率高于B基因型(0.4%比5.3%,χ~2=12.23,P<0.01),M204I/V,L180M、T184A/G/I/S、S202G/I和V173L变异发生率在B、C基因型之间差异无统计学意义(P值均>0.05).M204I在B基因型的发生率为20.6%,高于C基因型的13.9%(χ~2=4.91,P<0.05);M204V和M201Ⅳ变异在B、C基因型中的发生率差异无统计学意义(χ~2值分别为1.70和2.21,P值均>0.05).拉米夫定耐药发生率在B、C基因型间差异无统计学意义(χ~2=0.00,P>0.05).结论 拉米夫定常见耐药位点在B、C基因型之间无明显差异,但是C基因HBV感染患者病毒载量高于B基因型HBV感染患者;M204I变异在B基因型中出现频率高于C基因型,拉米夫定加用或改用阿德福韦酯后可能会使A181V/T变异在C基因型出现的概率高于B基因型;年龄、免疫因素和非常见位点的变异或许是影响拉米夫定疗效的重要因素.