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Chronic hepatitis B virus infection is prevalent worldwide, and can progress to liver cirrhosis and even hepatocellular carcinoma if left untreated. Over the past 20 years, due to the approval and upgrading of nucleoside/nucleotide analogues, a qualitative leap has been made in inhibiting HBV replication. Most chronic hepatitis B (CHB) patients can achieve relief of hepatocellular inflammation, regression of hepatic fibrosis, improvement of life quality and survival time. With the extension of treatment time and the enrichment of treatment experience, new hot clinical issues gradually emerge, including the clinical application of new serum markers, the expansion of indicators for CHB antiviral treatment, the formation of CHB treatment plan and the improvement of long-term prognosis, which derserve further clinical attention.

, correspAuthors=Yong-Ping Yang, authorNote=null, correspAuthorsNote=
E-mail:
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乙型肝炎病毒慢性感染呈世界性流行态势,如不及时治疗,可持续进展至肝硬化甚至肝细胞癌。近20年来,由于核苷(酸)类似物的上市及更新换代,在抑制乙肝病毒复制方面取得了质的飞跃,大多数慢性乙型肝炎(CHB)患者均可实现减轻肝细胞炎症及纤维化、改善生活质量、延长生存时间等目标。随着治疗时间的延长及治疗经验的积累,新的热点问题逐渐浮现,包括新型血清学标志物在临床的应用,CHB抗病毒治疗适应证的扩大、CHB治疗方案的制定以及长期预后的改善等,值得临床进一步关注。

, correspAuthors=杨永平, authorNote=null, correspAuthorsNote=
杨永平,E-mail:
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纪冬,主任医师,副教授,主要从事病毒性肝炎、肝硬化等方面的临床与基础研究

杨永平,主任医师,教授,博士研究生导师,解放军总医院第五医学中心肝病医学部主任。中国研究型医院学会肝病专业委员会主任委员,中国肝炎基金会专家委员会理事,中华医学会北京分会肝病专业委员会副主任委员。牵头国家“十三五”及“十二五”重大专项课题,军队“十二五”重点课题和北京市科委军民融合重点课题多项;享受国务院政府特殊津贴;获国家科技进步奖1项,北京市科学技术进步一等奖1项,军队科技进步二等奖6项

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慢性乙型肝炎临床热点问题解析
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纪冬 , 杨永平 *
解放军医学杂志 | 专家述评 2023,48(2): 132-137
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解放军医学杂志 | 专家述评 2023, 48(2): 132-137
慢性乙型肝炎临床热点问题解析
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纪冬, 杨永平*
作者信息
  • 解放军总医院第五医学中心肝病医学部,北京 100039
  • 纪冬,主任医师,副教授,主要从事病毒性肝炎、肝硬化等方面的临床与基础研究

    杨永平,主任医师,教授,博士研究生导师,解放军总医院第五医学中心肝病医学部主任。中国研究型医院学会肝病专业委员会主任委员,中国肝炎基金会专家委员会理事,中华医学会北京分会肝病专业委员会副主任委员。牵头国家“十三五”及“十二五”重大专项课题,军队“十二五”重点课题和北京市科委军民融合重点课题多项;享受国务院政府特殊津贴;获国家科技进步奖1项,北京市科学技术进步一等奖1项,军队科技进步二等奖6项

通讯作者:

杨永平,E-mail:
Analysis of clinical hot issues of chronic hepatitis B
Dong Ji, Yong-Ping Yang*
Affiliations
  • Senior Department of Hepatology, the Fifth Medical Center of Chinese PLA General Hospital, Beijing 100039, China
出版时间: 2023-02-28 doi: 10.11855/j.issn.0577-7402.2023.02.0132
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乙型肝炎病毒慢性感染呈世界性流行态势,如不及时治疗,可持续进展至肝硬化甚至肝细胞癌。近20年来,由于核苷(酸)类似物的上市及更新换代,在抑制乙肝病毒复制方面取得了质的飞跃,大多数慢性乙型肝炎(CHB)患者均可实现减轻肝细胞炎症及纤维化、改善生活质量、延长生存时间等目标。随着治疗时间的延长及治疗经验的积累,新的热点问题逐渐浮现,包括新型血清学标志物在临床的应用,CHB抗病毒治疗适应证的扩大、CHB治疗方案的制定以及长期预后的改善等,值得临床进一步关注。

乙型肝炎,慢性  /  诊断  /  治疗  /  预后

Chronic hepatitis B virus infection is prevalent worldwide, and can progress to liver cirrhosis and even hepatocellular carcinoma if left untreated. Over the past 20 years, due to the approval and upgrading of nucleoside/nucleotide analogues, a qualitative leap has been made in inhibiting HBV replication. Most chronic hepatitis B (CHB) patients can achieve relief of hepatocellular inflammation, regression of hepatic fibrosis, improvement of life quality and survival time. With the extension of treatment time and the enrichment of treatment experience, new hot clinical issues gradually emerge, including the clinical application of new serum markers, the expansion of indicators for CHB antiviral treatment, the formation of CHB treatment plan and the improvement of long-term prognosis, which derserve further clinical attention.

hepatitis B, chronic  /  diagnosis  /  treatment  /  outcome
纪冬, 杨永平. 慢性乙型肝炎临床热点问题解析. 解放军医学杂志, 2023 , 48 (2) : 132 -137 . DOI: 10.11855/j.issn.0577-7402.2023.02.0132
Dong Ji, Yong-Ping Yang. Analysis of clinical hot issues of chronic hepatitis B[J]. Medical Journal of Chinese People’s Liberation Army, 2023 , 48 (2) : 132 -137 . DOI: 10.11855/j.issn.0577-7402.2023.02.0132
乙型肝炎病毒(hepatitis B virus,HBV)慢性感染可引起肝炎、肝硬化甚至肝癌,严重威胁着患者的生命健康[1]。抗病毒治疗可明显抑制HBV复制,是最重要的治疗方法[2]。但近年来随着治疗时间的延长及治疗经验的积累,出现了新的临床热点问题,包括疗效的评价与监测指标、治疗适应证的扩大、治疗方案的制定、长期预后的改善等,本文主要针对这几个方面进行论述。
HBcrAg包括HBeAg、HBcAg及中间产物22 kD前核心蛋白,这3个蛋白均由Pre-C/C开放读码框编码,共用一段149个氨基酸的序列,可被相同的抗体检出。HBcrAg阳性与接受抗病毒治疗者肝细胞内的HBV DNA及前基因组RNA (pre-genomic RNA,pgRNA)水平相关,使其可作为新型血清学标志物用于评价肝细胞内共价闭合环状DNA (covalently closed circular DNA,cccDNA)转录活性以及转变为肝细胞癌(hepatocellular carcinoma,HCC)风险的高低[3-5]
HBV RNA是另一个具有良好临床应用前景的新型血清学标志物。1996年,德国研究者Köck等[6]在慢性乙型肝炎(chronic hepatitis B,CHB)患者血清中发现了HBV RNA的存在,之后证明血清中HBV RNA的来源实为未经反转录的pgRNA,存在于病毒颗粒的核衣壳内,这种病毒颗粒被称为“HBV RNA病毒样颗粒”[7]。HBV RNA在监测抗病毒治疗应答及停药决策、评估功能治愈、判断HCC风险、确定肝内cccDNA等方面均可发挥重要作用,特别在未来监测新型抗HBV治疗应答方面将是一个非常有价值的工具。
一项研究回顾性收集了227例接受肝活检的HBV感染患者的血清,并定量检测其血清HBV RNA、HBcrAg、Anti-HBc水平,以及肝组织HBV tDNA、cccDNA水平,结果表明HBcrAg可用于鉴别急性乙型肝炎是否彻底治愈或转变为隐匿性感染,即使HBV DNA已降至不可测,但只要能检出HBV RNA,则仍应继续抗病毒治疗;HBV RNA及HBcrAg或可作为肝组织HBV cccDNA的血清学替代指标[8]。总之,这些新型血清学标志物有望替代传统标志物以更好地监测HBV感染不同自然病程分期的特征,预测抗病毒应答,且在新药研发中具有较高的价值,已成为研究热点[9-10]
在CHB的治疗中,抗病毒是最重要的,其适应证有进一步扩大的趋势。欧洲肝病学会及中国指南建议,HBV DNA升高及谷丙转氨酶(alanine aminotransferase,ALT)升高的患者应接受抗病毒治疗[11-12]。但也有研究显示,在ALT正常的患者中,27%出现明显的肝脏炎症(≥G2),36%有肝纤维化(≥F2),18%为肝硬化,且ALT正常与ALT升高患者的肝纤维化分期及肝硬化发生率无明显差异[13],HBV感染ALT正常患者的病情严重程度可能无法通过ALT水平来反映。因此,正常的ALT不应被认为是抗HBV治疗的排除指标,有相当一部分ALT正常的患者也有接受抗病毒治疗的必要性。
目前国内外指南对于免疫耐受期的定义尚存在争议[14-15],ALT正常上限的标准亦不同,按照美国肝病学会的标准意味着我国此类患者并非全部处于免疫耐受阶段。单纯用病毒学、ALT水平评估免疫耐受可能存在临床误判[16]。“真正”的免疫耐受需在肝活检基础上进一步确诊,此类患者是否应行抗病毒治疗逐渐成为热点问题。据报道,5%~49%的免疫耐受患者存在明显的肝脏炎症及纤维化,导致其发生肝硬化及HCC的风险增加[17-18]。有研究表明,接受抗病毒治疗可降低不良结局的风险,且早期治疗具有明显的成本效益[19-20]
临床上存在相当比例的患者,其HBV DNA及ALT模式无法归类于传统的4个慢性HBV感染分期,称之为“不确定期”。但目前尚无指南明确提出“不确定期”的定义,且单纯用病毒学、ALT水平评估不确定期可能忽视部分不符合肝活检组织学分期的患者,“真正”的不确定期需在肝活检的基础上进一步确定。根据不同的ALT正常上限标准,在初治慢性HBV感染者中,不确定期CHB患者的占比为27.8%~59.0%,未接受抗病毒治疗的不确定期患者发生肝硬化甚至HCC的风险高于非活动期患者,高龄、HBeAg阳性、高ALT水平是此类患者预后不良的危险因素[21-22]。近期有学者提出,在有明显疾病进展证据时,应早期启动抗病毒治疗,以降低此类患者发生HCC的风险[23]。不确定期CHB患者是否需要接受抗病毒治疗也是目前的研究热点,需要更多的循证医学证据[24-25]
一线核苷(酸)类似物(nucleos(t)ide analogues,NAs)药物可强效抑制病毒复制,实现完全病毒学应答(complete virological response,CVR),然而相当一部分患者始终无法获得CVR,美国肝病研究学会将其定义为LLV,指的是经NAs治疗12个月后,HBV DNA持续或间歇大于检测下限但小于2000 IU/ml[26]。经治CHB患者的LLV现象已成为乙肝治疗领域的前沿及热点问题。研究表明,20.0%~37.9%的经治CHB患者会产生LLV,导致耐药突变增多、肝纤维化进展甚至罹患HCC,其对预后的影响不可忽视[27]。近期研究发现,将原有的恩替卡韦换为丙酚替诺福韦可以明显提高LLV患者的病毒学应答率,但均为小样本研究[28-29]。LLV现象日益凸显,但其发生机制尚不明确。LLV与HBV耐药突变的因果关系如何,临床上有哪些高危因素,如何影响患者的预后,如何制定更合理的抗病毒初治方案及挽救治疗方案,维持原治疗方案、换药、加药哪种策略更安全有效,都是未来需要研究的方向。本课题组回顾性筛选2096例存在LLV的经治CHB患者,采用巢式PCR扩增HBV的RT片段并进行双向测序,发现LLV耐药突变基因型以拉米夫定及阿德福韦耐药为主,并降低了恩替卡韦耐药的基因屏障,提高了恩替卡韦的耐药比例,故抗病毒治疗应选择强效低耐药的一线药物[30]
尽管肝活检仍然是评价肝脏纤维化的金标准,但由于其为有创检查,存在发生各种并发症(如疼痛、出血)的潜在危险,且抽样误差极大地影响了肝纤维化分级结果,同时也不适用于动态监测,因此无创检测技术是未来重要的研究方向[31-32]。在多种无创诊断方法中,肝弹性检测(liver stiffness measurement,LSM)是应用最广泛的技术之一。目前多数研究认为LSM下降与肝脏炎症减轻、肝纤维化缓解存在相关性,可间接反映肝纤维化的缓解[33]。但目前对于LSM的临床应用仍需要进一步深入理解,如LSM下降到什么水平能够代表肝组织学改善或逆转,治疗过程中LSM的变化是否与长期预后相关等。既往研究显示,LSM下降除了上述2个原因之外,还存在因多次检测造成的随机误差,所以使用LSM下降来评价肝纤维化的缓解存在假阳性可能,对于抗病毒治疗过程中LSM的下降要谨慎分析,不能过于乐观地认为LSM下降就是发生了肝纤维化缓解或逆转[34]
本课题组对来自一项前瞻性队列研究的727例CHB患者的临床数据进行了分析,结合抗病毒治疗前及治疗后72周的肝活检信息,构建了基于基线年龄、血小板、LSM及72周ALT、LSM的列线图模型,可以更加准确地评估CHB患者抗病毒治疗期间的明显组织学应答(抗病毒治疗后肝组织纤维化Ishak评分F≤2分,且肝脏炎症活动指数HAI≤4分)情况[35]。另有回顾性研究分析了470例HBV相关肝硬化患者的临床信息,分为食管胃底静脉曲张(esophageal and gastric varices,EGV)组178例,以及无EGV组292例,多因素分析结果显示基于血小板、LSM及脾直径的肝脾比例(liver-to-spleen ratio,LSPS)可用于预测乙型肝炎肝硬化代偿期患者发生EGV的风险,较谷草转氨酶、血小板比率指数(aspartate aminotransferase/platelet ratio index,APRI)、肝纤维化4因子(fibrosis-4,FIB-4)及LSM的预测价值更高,可使部分患者免于内镜检查[36]。这些研究都体现了LSM可与其他指标联合,以进一步提高辅助诊疗的效能。
丁型肝炎病毒(hepatitis D virus,HDV)感染可发生于急、慢性HBV感染的任一时间点。HDV是一种小RNA病毒,依赖于HBsAg的存在进行传播,据估计全世界有1500万至2000万人存在慢性HDV感染。HDV重叠其他类型感染会导致肝脏疾病加重,加速发展为肝硬化或肝功能失代偿。重要的是,在大多数患者中,HDV感染可导致HBV感染的抑制,其长期临床结局与患者的HBeAg状态无关[37-38]。在接受NA治疗且获得持续病毒应答的患者中,如果肝纤维化持续进展,需要注意有无HDV的重叠感染。
慢性HBV感染及肝纤维化进展是HCC发生发展最重要的危险因素。NA治疗可降低HCC的发病风险已得到普遍认可。然而目前的抗病毒治疗,包括NA或聚乙二醇干扰素治疗,均不能完全根除HBV(以HBsAg转阴为标志),其逆转肝纤维化/肝硬化的疗效有限。CHB患者发生HCC的风险只能降低,而不能消除,抗病毒治疗联合抗纤维化治疗(“双抗”)是目前进一步降低HCC发生率的有效策略。中医药在抗纤维化领域具有独特的优势,目前多个药物(复方鳖甲软肝片、扶正化瘀胶囊、安络化纤丸)均已经过多中心前瞻性临床研究证实在有效缓解肝纤维化方面获得了高水平的循证医学证据[39-41],它们与抗病毒药物联合使用理论上可以进一步降低HCC的发生率,期待通过更多的研究加以验证。
非酒精性脂肪性肝病(non-alcoholic fatty liver disease,NAFLD)是近年来的研究热点,全世界约有10亿人患NAFLD,可进展为晚期肝纤维化、肝硬化、HCC及与肝脏相关的致死性并发症。多项研究发现NAFLD与HCC的发生明显相关[42-43],但有部分研究认为HBV相关HCC患者与NAFLD相关HCC患者生存率并无明显差别,NAFLD及HBV感染作为HCC的病因并非预后不良的危险因素[44-46]。有研究回顾性分析了833例HBV相关HCC患者,按照可切除及不可切除分层,并进行稳健逆概率处理加权法消除混杂因素,结果发现合并NAFLD患者的累积生存率较未合并NAFLD者更高[47]。CHB合并NAFLD患者HCC的发生率、生存率如何,需要进一步研究以提供更多的循证医学证据。
为优化HCC监测,可采用基于评分的风险预测方法,在不同的环境下选择不同的评分,如LSM-HCC[48]、CU-HCC[49]、REACH-B[50]、PAGE-B评分等[51]。低风险患者可能不需要密切监测,但高风险患者需要密切随防,以早期发现HCC。然而需要注意的是,这些评分模型有一些局限性,部分已被证实对HCC发展风险具有预测价值的标志物(如HBsAg水平、HBV基因型)并未包括在上述评分模型中,部分评分来自未经治疗的患者,抗病毒治疗强烈影响病毒因素,从而导致过高估计HCC的发病率。另外对于HCC生存的评估,可以进一步辅助制定更加精准化的治疗方案[52-53],也是目前研究的热点。
安全有效的乙肝疫苗接种可预防HBV的传播,极大程度地减少新发患者。对于已经感染HBV的患者,虽可获得安全有效的抗病毒治疗,但大部分此类患者的疗程,目前而言没有明确期限,须等到新的抗病毒药物出现[54]。对于特殊人群,如处于免疫耐受期、不确定期以及LLV患者的治疗策略仍需要深入研究。对于肝硬化进展风险、HCC发生风险较高的患者,需要继续完善预测模型,从而早期发现、早期调整治疗方案,最终达到进一步提高治疗有效率、改善生活质量、延长生存时间的目标。
  • 北京市自然科学基金面上项目(7222173)
  • 国家“十三五”科技重大专项(2018ZX10725506)
  • 解放军总医院医疗大数据与人工智能研发项目(2019MBD-024)
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2023年第48卷第2期
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doi: 10.11855/j.issn.0577-7402.2023.02.0132
  • 接收时间:2022-06-17
  • 首发时间:2025-12-03
  • 出版时间:2023-02-28
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  • 收稿日期:2022-06-17
  • 录用日期:2022-09-17
基金
Beijing Natural Science Foundation(7222173)
北京市自然科学基金面上项目(7222173)
National Science and Technology Major Project of "13th Five-year Plan" of China(2018ZX10725506)
国家“十三五”科技重大专项(2018ZX10725506)
Project of Medical Big Data and Artificial Intelligence Research and Development of Chinese PLA General Hospital(2019MBD-024)
解放军总医院医疗大数据与人工智能研发项目(2019MBD-024)
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    解放军总医院第五医学中心肝病医学部,北京 100039

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杨永平,E-mail:
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2种不同金属材料的力学参数

Family
属数
Number of
genus
种数
Number of
species
占总种数比例
Percentage of
total species (%)

Genus
种数
Number of
species
占总种数比例
Percentage of total
species (%)
鹅膏菌科Amanitaceae 2 11 5.26 鹅膏菌属 Amanita 10 4.78
小菇科 Mycenaceae 2 12 5.74 丝盖伞属 Inocybe 5 2.39
多孔菌科 Polyporaceae 8 14 6.70 蜡蘑属 Laccaria 5 2.39
红菇科 Russulaceae 3 23 11.00 小皮伞属 Marasmius 6 2.87
小菇属 Mycena 11 5.26
光柄菇属 Pluteus 5 2.39
红菇属 Russula 17 8.13
栓菌属 Trametes 5 2.39
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