预存耐药检测选择药物治疗对慢性乙肝患者抗病毒治疗效果的影响及其重要意义

目的探讨对未经核苷(酸)类似物治疗的慢性乙型肝炎患者进行预存耐药检测并根据检测结果选择药物进行治疗对患者临床治疗效果的影响,分析预存耐药检测对抗病毒治疗方案选择的意义。方法选择清远市人民医院感染科2016年7~12月未经核苷(酸)类似物治疗的慢性乙肝患者400例,按照随机数字表法将患者分为两组,每组200例。观察组患者在治疗前进行预存耐药基因检测,根据预存耐药检测结果选择合适核苷类似物(NAs)治疗;对照组不进行耐药检测,依患者意愿选择药物进行治疗,疗程48周。检测比较两组患者的HBe Ag阴转率、HBe Ag血清学转换率、HBV-DNA转阴率、ALT复常率、耐药率及血清HBV-DNA定量情况。结果治疗36周和48周后,观察组患者的HBe Ag阴转率及HBe Ag血清学转换率显著高于对照组患者(P0.05);治疗24周、36周、48周后,观察组患者的HBV-DNA转阴率和血清ALT复常率均显著高于对照组(P0.05)。治疗前两组患者的血清HBV-DNA定量比较差异无统计学意义(P0.05),治疗12周、24周、36周、48周后观察组患者血清HBV-DNA定量显著低于对照组(P0.05);治疗12周、24周、36周、48周后观察组患者的耐药率均显著低于对照组(P0.05)。结论乙型肝炎患者抗病毒治疗前进行预存耐药基因检测并根据检测结果选择药物进行治疗,可显著提高抗病毒治疗应答,减少原发耐药的发生,提高患者的临床治疗效果,对有效防控慢性乙型肝炎的流行具有重要意义。     

慢性乙型肝炎患者HBV核苷（酸）类似物预存耐药基因突变的研究

目的分析慢性乙型肝炎患者HBV核苷(酸)类似物(NAs)预存耐药基因变异的情况,提高慢性乙型肝炎防控水平。方法选择2016年7月至2017年9月于清远市人民医院感染科就诊的未经NAs治疗的慢性乙型肝炎患者600例,随机分成两组,观察组治疗前进行预存耐药基因检测,根据检测结果给予相应的NAs治疗,对照组300例不进行耐药检测,依患者意愿选择药物进行治疗,疗程72周。治疗期间对两组患者的HBV DNA转阴率、耐药率等进行检测对比。结果300例观察组患者中29例发生不同位点变异,变异率9.6%;包含与拉米夫定耐药相关的20例(69.0%),与替比夫定耐药相关的19例(65.5%),与阿德福韦酯耐药相关的7例(24.1%),同时发现4例对恩替卡韦主要耐药位点部分位点基因突变;观察组HBV DNA转阴率显著高于对照组,而耐药率则显著低于对照组。结论研究地区慢性乙型肝炎患者HBV NAs预存耐药基因变异主要发生拉米夫定、替比夫定及阿德福韦酯;在抗病毒治疗前检测耐药基因,可显著提高抗病毒治疗应答,减少原发耐药的发生。     

核苷(酸)类似物联合干扰素治疗HBeAg阳性慢性乙型肝炎120周的疗效随访

目的 观察核苷(酸)类似物联合干扰素延长疗程至96周治疗HBeAg阳性慢性乙型肝炎,随访24周的疗效. 方法 135例HBeAg阳性慢性乙型肝炎患者,90例接受核苷(酸)类似物联合干扰素治疗(联合治疗组),45例接受单一核苷(酸)类似物治疗(对照组).分别在治疗12、24、48、72、96周及随访24周时进行生物化学、病毒学、血清学评估.应答疗效比较采用x2检验. 结果 135例患者纳入分析.联合治疗组90例完成96周疗程后,17例(占18.9％)患者发生HBsAg血清学转换,37例(占41.1％)患者发生HBeAg血清学转换;对照组无患者发生HBsAg血清学转换,15例(占33.3％)患者发生HBeAg血清学转换,联合治疗组HBsAg血清学转换明显高于对照组,x2=8.08,P＜ 0.01,差异有统计学意义.两组患者HBeAg血清学转换差异无统计学意义.出现HBsAg血清转换＜ 30岁为64.7％ (11/17),30 ～ 40岁为9.7％(6/62),＞40岁11例中无一例出现HBsAg血清转换,＜ 30岁患者HBsAg血清转换率明显高于其他年龄组,x2值分别是12.62和4.24,P值均＜0.05,差异有统计学意义. 结论 核苷(酸)类似物联合干扰素延长疗程治疗HBeAg阳性慢性乙型肝炎能提高HBsAg血清学转换,年龄＜30岁者出现HBsAg血清学转换比例最高.     

340例慢性乙型肝炎患者乙型肝炎病毒多位点耐药相关突变分析

目的 分析慢性乙型肝炎患者HBV逆转录酶基因与核苷(酸)类似物耐药相关的12个位点上的突变情况及其临床意义.方法 提取血清HBV DNA,扩增HBV逆转录酶基因,对PCR产物进行DNA双向测序,对测序成功的样本进行基因型分析.检测逆转录酶基因12个位点上的碱基突变情况,分析不同核苷(酸).类似物使用情况、患者的耐药相关突变情况及不同核苛(酸)类似物耐药的突变形式. 结果 检出拉米夫定耐药突变63例,阿德福韦耐药突变10例,恩替卡韦耐药突变8例,替比夫定耐药突变1例.拉米夫定耐药突变中以M204V和M204I最常见,前者通常伴随L180M突变,后者常单独出现,阿德福韦耐药中以N236T±A181位碱基替换为主;恩替卡韦耐药突变发生在拉米夫定耐药基础上,以T184位碱基替换为主;替比夫定的耐药突变为M204I.少数未接受过核苷(酸)类似物治疗的患者也可检出耐药相关突变.结论 检测HBV逆转录酶基因多位点耐药相关突变,有助于临床及时发现和确认乙型肝炎患者是否存在HBV耐药,合理进行抗病毒治疗.     

乙型肝炎病毒逆转录酶区预存耐药研究

目的探讨未经核苷(酸)类似物治疗的乙型肝炎病毒(HBV)感染者HBV P基因逆转录(RT)区准种异质性及预存耐药情况,为临床抗病毒治疗药物选择提供理论依据。方法 2011年10月至2013年4月期间于中国医科大学附属盛京医院感染科住院的60例慢性HBV感染者为研究对象。检测HBV P RT区准种异质性及预存耐药情况;乙型肝炎病毒血清学标志物检测采用化学发光法;乙型肝炎病毒载量测定采用Tag Man实时荧光定量PCR法。HBV P RT准种异质性及预存耐药检测应用克隆测序法。结果 60例患者中32例(53.3%)检测出RT区基因变异,其中乙肝病毒携带者组、慢性乙型肝炎组和乙肝肝硬化组之间相比差异无统计学意义(P0.05)。对HBV RT区的核苷酸序列分析共发现31种变异模式。拉米夫定预存耐药8例(1.33%)、恩替卡韦预存耐药5例(0.83%),阿德福韦酯预存耐药7例(1.16%)。乙肝肝硬化组准种复杂性(38.3%)明显高于慢性乙型肝炎(2.83%)和乙肝病毒携带者(1.33%)。e抗原(HBe Ag)阳性组RT区变异发生率为52.6%,阴性组为54.5%,两组差异无统计学意义。结论 HBV逆转录酶区核苷(酸)预存耐药天然存在,变异模式多种多样。HBV不同感染阶段RT区各耐药位点变异发生率差异无统计学意义,但乙肝肝硬化组准种复杂性明显高于慢性乙型肝炎和乙型肝炎病毒携带者。HBe Ag阳性和阴性HBV感染者RT区基因变异率差异无统计学意义。     

核苷(酸)类似物序贯干扰素治疗乙型肝炎病毒e抗原阳性慢性乙型肝炎患者的临床观察

目的 观察HBeAg阳性慢性乙型肝炎(CHB)患者在核苷(酸)类似物抗病毒治疗基础上序贯聚乙二醇干扰素α-2a(PEG IFNα-2a)治疗48周血清HBsAg的变化.方法 6例HBeAg阳性CHB患者中,3例采用核苷(酸)类似物序贯PEG IFNα-2a治疗48周,3例维持原核苷(酸)类似物治疗方案,每12周采用实时PCR定量检测HBV DNA,采用时间分辨免疫荧光分析法检测HBsAg、抗-HBs、HBeAg、抗-HBe及抗-HBc.结果 核苷(酸)类似物序贯PEG lFNα-2a治疗48周后,3例序贯治疗患者血清HBsAg均消失,而维持原核苷(酸)类似物治疗患者血清HBsAg效价为100～320 IU/mL.结论 对核苷(酸)类似物治疗产生较好应答反应且伴有血清HBsAg效价明显下降的HBeAg阳性CHB患者,在核苷(酸)类似物抗病毒治疗基础上序贯PEG IFNα-2a治疗48周能有效促进血清HBsAg下降,并出现血清HBsAg消失的现象.     

核苷(酸)类似物对慢性乙型病毒性肝炎患者肾小球滤过率的影响

目的 比较核苷(酸)类似物抗病毒治疗前后对肾小球滤过率的影响,分析可能的影响因素.方法 以慢性乙型肝炎患者为研究对象,分为恩替卡韦治疗组(0.5 mg/d)、阿德福韦酯治疗组(10 mg/d)和替比夫定治疗组(600 mg/d).观察抗病毒治疗52周后各组肾小球滤过率(GFR)的变化,并进行3组患者治疗前后HBeAg血清学转换率、GFR升高≥10mL/(min·1.73 m2)及治疗后GFR≥90 mL/(min· 1.73 m2)的比较,以及出现HBeAg血清学转换患者治疗前后GFR的比较.结果 替比夫定组在治疗52周后GFR升高(P＜0.05);治疗前后GFR升高≥10 mL/(min·1.73 m2)的患者比例替比夫定组优于阿德福韦酯组(P＜0.05).结论 替比夫定抗病毒治疗后慢性乙型肝炎患者GFR得到改善.     

核苷(酸)类似物抗病毒治疗对慢性乙型肝炎患者焦虑和抑郁状态的影响

目的 探讨核苷(酸)类似物抗病毒治疗对慢性乙型肝炎患者的焦虑和抑郁状态的影响,并分析其影响因素.方法 用中文版焦虑自评量表(SAS)和抑郁自评量表(SDS)测量核苷(酸)类似物抗病毒治疗的120例慢性乙型肝炎患者治疗前、治疗1年和治疗2年时的焦虑和抑郁状态.记录患者的人口学资料,并定期检测患者的ALT和HBV DNA等指标.计数资料采用x2检验,计量资料采用t检验、单因素方差分析,多因素Logistic回归分析.结果 慢性乙型肝炎患者抗病毒治疗前、治疗1年、治疗2年的SAS、SDS平均得分随抗病毒治疗时间的延长而降低(F=12.661、22.395,均P＜0.01).治疗前、治疗1年、治疗2年时SAS、SDS得分大于50分的患者分别为5.8％、4.2％、1.7％和13.3％、7.5％、5.0％.治疗2年时,HBV DNA转阴和未转阴的患者,焦虑改善率分别为69.0％、22.2％(x2 =22.325,P＜0.01);抑郁改善率分别为77.4％、22.2％(x2＝32.179,P＜0.01).多因素Logistic回归分析显示,与HBV DNA未阴转的患者相比,阴转的患者焦虑、抑郁改善的比值比(OR)及其95％可信区间(CI)分别为7.751 (3.026～19.853)、15.069(5.309～42.770);与ALT未复常的患者相比,ALT复常的患者抑郁改善的OR值及其95％CI为4.103(1.376～12.238).结论 核苷(酸)类似物抗病毒治疗能改善慢性乙型肝炎患者的焦虑和抑郁状态.HBV DNA阴转是焦虑和抑郁改善的独立影响因素.     

乙型肝炎病毒的耐药及处理核苷(酸)类似物耐药变异对乙型肝炎病毒生物学特性的影响

目前,所有口服核苷(酸)类似物抗病毒药物,包括拉米夫定、阿德福韦、恩替卡韦、替比夫定等,在长期抗乙型肝炎病毒(HBV)治疗过程中都可能出现耐药.随着核苷(酸)类似物抗病毒药物在临床上广泛应用于治疗慢性乙型肝炎,HBV耐药问题日益凸显,成为制约慢性乙型肝炎抗病毒疗效的主要因素.HBV发生耐药变异之后,其生物学特性,包括复制能力、分泌能力、包装能力和抗原性都可发生相应变化.本文就核苷(酸)类似物抗病毒药物耐药变异对HBV生物学特性的影响作一概述.     

核苷(酸)类似物长期治疗的常见耐药位点及发生率

目前批准的核苷(酸)类似物如拉米夫定、阿德福韦、恩替卡韦等可抑制HBV复制。然而,HBV闭合环状DNA (cccDNA)存在于感染细胞核中,需要延长治疗时间以达到防止停药后病毒复制反弹。伴随治疗时间延长出现的问题就是发生选择性抗病毒药物耐药突变。随着核苷(酸)类抗病毒药物的应用,抗病毒药物耐药突变已经成为目前临床医师进行CHB治疗面临的主要问题,由于不同核苷(酸)类似物抗病毒耐药变异位点和变异发生率不同,为了便于临床监测和选     

替诺福韦挽救治疗耐药复发的慢性乙型肝炎患者48周疗效初探

目的观察替诺福韦（TDF）单药或联合恩替卡韦（ETV）挽救治疗耐药复发的慢性乙型肝炎患者的疗效及安全性。方法回顾性分析11例耐药复发的慢性乙型肝炎患者的挽救治疗,其中6例患者单用TDF,5例患者采用TDF联合ETV。采用时间分辨免疫荧光法检测血清乙型肝炎病毒标志物,采用脱氧核糖核酸测序法检测与耐药相关的HBV P区169、173、180、181、184、202、204、233、236、250位耐药变异,采用PCR-荧光探针法检测血清HBV DNA载量,采用苦味酸法检测血清肌酐（Cr）水平。应用Kaplan-Meier分析血清HBV DNA累积不可检出率。结果挽救治疗前,1例患者检测到ADV基因型耐药,7例患者检测到LAM/ETV基因型耐药,3例患者检测到LAM/ETV/ADA基因型耐药;HBV DNA基线水平为（4.82±1.29） lg IU/ml,挽救治疗第4周降至（3.57±0.55） lg IU/ml,第12周降至（2.91±0.37） lg IU/ml,随访至第48周,仅1例患者可检测出HBV DNA。挽救治疗4、12、24和36周,血清HBV DNA累积不可检出率分别为36.4%（4/11）、63.6%（7/11）、81.8%（9/11）和90.9%（10/11）;随访结束时,血清ALT水平由（64.36±34.55） U/L降至（37.7±24.49） U/L;治疗期间未发生肾功能异常或其他不良事件。结论TDF单药或联合ETV挽救治疗耐药复发的慢性乙型肝炎患者仍能较快速地抑制病毒复制,具有良好的疗效和安全性。     

抗HBV核苷(酸)类新药研究进展

近年开发了许多抗HBV核苷(酸)类新药,有些已经在国外上市,有些仍处于临床试验阶段。与国内临床上应用的抗HBV核苷(酸)类药物相比,这些新药具有抗病毒作用强、耐药发生率低、患者耐受性好等优点,但也存在一些问题,如停药后易复发、随着疗程延长产生耐药的趋势增加等。本文对抗HBV核苷(酸)类新药的研究进展进行综述,以使临床医生对核苷(酸)类新药有更加深入的了解,为慢性乙型肝炎患者的抗病毒治疗提供更多选择。     

Resistance is no Longer a Problem with Entecavir and Tenofovir

The treatment of chronic hepatitis B has been transformed with the advent of nucleos(t)ide analogues. With this came the recognition of viral resistance which was defined as rebound of viral HBV DNA >1 log from nadir associated with genotypic mutations of viral resistance. Resistance was associated with loss of efficacy, with the clinical consequences of viral relapse, reactivation of chronic hepatitis B, increased risk of hepatitis B flares, liver decompensation, and increased mortality especially in cirrhotic patients. Resistance rates varied between different nucleos(t)ide analogues and were generally classified as low or high genetic barrier to resistance. Different pathways to development of viral resistance were recognized, with therapeutic options for rescue therapy determined by such pathways. The two high genetic barrier drugs, entecavir and tenofovir showed remarkably low or absence of viral resistance in treatment naïve patients over 5 years or longer of therapy. However in treatment-experienced patients, particularly those with viral resistance, results were less optimal. For entecavir, prior lamivudine resistance conferred an entecavir resistance rate of 43 % over 5 years while with tenofovir, although resistance did not seem apparent, patients with prior adefovir resistance had suboptimal responses to tenofovir therapy. In cases of multiresistant hepatitis B virus defined as resistance to at least two nucleos(t)ide analogues in the same viral strain, rescue with a combination of tenofovir and entecavir appeared highly efficacious. Consequently, the optimistic view that these new drugs lead to absence of resistance needs to be tempered by the larger burden of drug experienced and drug resistant patients compared to treatment naïve patients. Furthermore, it is unclear whether resistance may be a concern with high genetic barrier drugs after one or two decades of therapy. In time, it is possible that with the increasing use of high genetic barrier drugs, viral resistance will be a lesser problem, but unlikely to disappear completely.     

Hepatitis B therapy

The goal of hepatitis B treatment is to prevent cirrhosis, liver decompensation and hepatocellular carcinoma. In clinical practice, treatment response is determined by suppression of serum HBV DNA levels, hepatitis B e antigen seroconversion to hepatitis B e antibody, hepatitis B surface antigen loss, normalization of alanine aminotransferase levels and improvement in liver histology. Patients with life-threatening liver disease, and those with high levels of HBV replication and active or advanced liver disease, should be treated. Other patients should be monitored so that treatment can be initiated when indicated. Currently, seven medications are approved for the treatment of hepatitis B: two formulations of interferon and five nucleos(t)ide analogues. Interferon is administered for a finite duration while nucleos(t)ide analogues are usually administered for many years. Antiviral drug resistance is a major limiting factor to the success of nucleos(t)ide analogue treatment; therefore, treatment should be initiated with drugs that have a high genetic barrier to resistance (that is, a low potential for drug resistance). In addition, treatment response should be closely monitored to detect virologic breakthroughs, and the importance of medication adherence should be emphasized. Management of patients with treatment failure should be tailored according to the type of treatment failure (lack of initial response versus virologic breakthrough), the treatment that the patient is receiving, history of prior treatment, and the pretreatment characteristics of both the patient and the disease.     

153例慢性HBV感染者核苷和核苷酸类药物的耐药变异位点分析

目的通过对153例慢性HBV感染者进行HBV逆转录酶区扩增测序,了解目前上市的核苷和核苷酸类药物耐药位点检出情况,并分析是否存在与替诺福韦耐药可能相关的耐药位点。方法 153例患者分为2组,其中78例是未使用过核苷和核苷酸类药物治疗的HBV携带者,75例是核苷和核苷酸类药物经治的慢性乙型肝炎患者。通过PCR扩增HBV的逆转录酶(RT)区,进行基因测序分析,了解核苷和核苷酸类药物的耐药位点及替诺福韦相关的耐药位点的检出情况。正态分布资料采用t检验,非正态分布的资料采用秩和检验。结果在未治疗组有7例检出核苷和核苷酸类相关的耐药变异,占该组的8.97%,但并无上述替诺福韦耐药相关的位点。治疗组检出16例耐药变异,占该组的21.33%,其中1例为rtA181T+rtN236T,可能与替诺福韦耐药相关。结论未治疗组中有8.97%的患者检出耐药变异。2组患者中耐药变异的检出率与患者的性别、年龄、病毒基因型均无显著相关。所有患者中仅1例检出rtA181T+rtN236T。提示中国慢性HBV感染者体内预存替诺福韦可能耐药位点的比例很低。     

Management of hepatitis B: Consensus of the Japan Society of Hepatology 2009

Recently, much progress has been made in the field of hepatitis B, such as natural history of the disease in relation to the amount of hepatitis B virus (HBV) DNA, genotypes of HBV influencing the natural course and treatment effects, mutations of HBV influencing the severity of the disease and development of hepatocellular carcinoma, and antiviral treatment such as nucleos(t)ide analogues and pegylated interferon. To make the consensus for the diagnosis, management and treatment of hepatitis B, a meeting was held during 45th annual meeting of Japan Society of Hepatology (JSH) in June 2009. In the meeting, recommendations and informative statements were discussed on the following subjects: (i) natural history of HBV infection; (ii) clinical implication of HBV genotypes; (iii) HBV mutations and their potential impact on pathogenesis of HBV infection; (iv) indications for antiviral treatment of chronic hepatitis B; (v) nucleos(t)ide analogues for chronic hepatitis B; and (vi) interferon therapy for chronic hepatitis B. The presenters reviewed the data on these subjects and proposed the consensus statements and recommendations. These statements were discussed among the organizers and presenters, and were approved by the participants of the meeting. In the current report, the relevant data were reviewed and the 12 consensus statements and nine recommendations on chronic hepatitis B were described.     

New developments in antiviral therapy for chronic hepatitis B

Chronic hepatitis B affects approximately 400 million people in the world with a substantial disease burden like liver cirrhosis and hepatocellular carcinoma (HCC). Treatment for chronic hepatitis B has improved dramatically in the last decade, resulting in more patients achieving a state of inactive disease. Currently two treatment strategies are available; treatment with peginterferon (peg‐IFN) or nucleos(t)ide analogues with the aim to suppress hepatitis B virus (HBV) DNA to subsequently avoid the development of cirrhosis and HCC. Unfortunately, treatment with peg‐IFN can be suboptimal with important adverse effects and nucleos(t)ide analogues provoke resistance. At present, no new promising compounds attacking the HBV life cycle are in development. However, for prediction of sustained response or treatment failure, data from the long‐term large peg‐IFN trials provide important response markers. For the future the focus is to achieve HBsAg loss and anti‐HBs conversion which is the closest the treatment can get to a cure. This review summarizes the current treatment options with their response rates and discusses future strategies for chronic hepatitis B treatment.     

Management of hepatitis B virus-related acute liver failure

Hepatitis B virus (HBV) is the most important cause of acute liver failure (ALF) in Eastern countries. HBV-related ALF may occur after acute HBV infection (A-ALF) or during acute exacerbation (flare) of chronic HBV infection (C-ALF). C-ALF may occur spontaneously or as a result of the effect of immunosuppression due to chemotherapeutic or immunosuppressive agents. The definition of HBV-related ALF is uncertain, because different diagnostic criteria are used in C-ALF, which may present as acute-on-chronic liver failure. Although the pathogenesis differs in the two subgroups of ALF, the symptoms and biochemical parameters can be similar. High titers of immunoglobulin M hepatitis B core antibody and lower viral loads are frequent in A-ALF as compared with C-ALF. The prognosis of C-ALF is significantly poor as compared with that of A-ALF. In C-ALF, most immunosuppression-mediated reactivation of hepatitis B results in fatality. Many case series or case-control studies have not demonstrated the survival benefit of nucleos(t)ide treatment. This treatment failure is probably related to delayed initiation of nucleos(t)ide treatment and viral suppression. Treatment with nucleos(t)ide analogs should be started immediately and should be continued regardless of subgroups of HBV-related ALF. Liver transplantation is the only treatment option that improves the prognosis of HBV-related ALF. Patients under consideration for transplantation should be given nucleos(t)ide analogs as prophylaxis to reduce the likelihood of post-transplant HBV recurrence.