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慢性HBV感染合并非酒精性脂肪性肝病:抗病毒治疗面临的问题

唐艳华 陆星宇 孙剑

唐艳华, 陆星宇, 孙剑. 慢性HBV感染合并非酒精性脂肪性肝病:抗病毒治疗面临的问题[J]. 临床肝胆病杂志, 2021, 37(7): 1508-1514. DOI: 10.3969/j.issn.1001-5256.2021.07.004
引用本文: 唐艳华, 陆星宇, 孙剑. 慢性HBV感染合并非酒精性脂肪性肝病:抗病毒治疗面临的问题[J]. 临床肝胆病杂志, 2021, 37(7): 1508-1514. DOI: 10.3969/j.issn.1001-5256.2021.07.004
TANG YH, LU XY, SUN J. Chronic hepatitis B virus infection with nonalcoholic fatty liver disease: Problems faced by antiviral therapy [J]. J Clin Hepatol, 2021, 37(7): 1508-1514. DOI: 10.3969/j.issn.1001-5256.2021.07.004
Citation: TANG YH, LU XY, SUN J. Chronic hepatitis B virus infection with nonalcoholic fatty liver disease: Problems faced by antiviral therapy [J]. J Clin Hepatol, 2021, 37(7): 1508-1514. DOI: 10.3969/j.issn.1001-5256.2021.07.004

慢性HBV感染合并非酒精性脂肪性肝病:抗病毒治疗面临的问题

DOI: 10.3969/j.issn.1001-5256.2021.07.004
基金项目: 

国家科技重大专项 2017ZX10202202

国家自然科学基金 82070614

国家自然科学基金 81871668

广东省”珠江人才计划”本土创新科研团队项目 2017BT01S131

详细信息
    通讯作者:

    孙剑,doctorsunjian@qq.com

  • 中图分类号: R512.62;R575.5

Chronic hepatitis B virus infection with nonalcoholic fatty liver disease: Problems faced by antiviral therapy

Funds: 

National Science and Technology Major Project of China 2017ZX10202202

National Natural Science Foundation of China 82070614

National Natural Science Foundation of China 81871668

Local Innovative and Research Teams Project of Guangdong Pearl River Talents Program 2017BT01S131

  • 摘要: 随着非酒精性脂肪性肝病(NAFLD)发病率的增加,慢性HBV感染合并NAFLD在临床实践中变得越来越普遍。在ALT升高的情况下,确定潜在原因并及时实施有效干预可降低疾病进展为肝硬化和肝细胞癌的风险。然而,国内外指南尚缺乏对慢性HBV感染合并NAFLD患者的临床管理建议。回顾了慢性乙型肝炎和NAFLD的新近指南,探讨合并NAFLD对慢性HBV感染者抗病毒治疗适应证、临床疗效和长期预后的影响,为这类患者的临床管理提供借鉴。

     

  • 表  1  各指南建议的单纯慢性HBV感染抗病毒治疗适应证

    实践指南 肝硬化分类 抗病毒治疗适应证
    HBV DNA(IU/ml) ALT1)
    APASL[10]
     2015年
    非肝硬化 >20 000 (HBeAg+)或>2000 (HBeAg-) ALT>2×ULN;ALT 1~ 2×ULN,活检显示中重度炎症或明显纤维化2)
    ≤20 000 (HBeAg+)或≤2000 (HBeAg-) ALT任意水平,活检显示中重度炎症或明显纤维化2)
    代偿期肝硬化 >2000 ALT任意水平
    可检测到 ALT>1×ULN
    失代偿期肝硬化 可检测到 ALT任意水平
    EASL[9]
     2017年
    非肝硬化 >2000 ALT>1×ULN,中/重度肝脏坏死性炎症或纤维化
    >20 000 ALT>2×ULN,不考虑炎症及纤维化程度
    >107(HBeAg+) ALT正常,有下列情况之一:(1)年龄>30岁,不考虑肝组织学损伤的严重程度;(2)有HBV相关肝外表现3)或有HCC/肝硬化家族史
    ≤2000 ALT正常,有HCC/肝硬化家族史或HBV相关肝外表现3)
    肝硬化 可检测到 ALT任意水平
    AASLD[2]
     2018年
    非肝硬化 >20 000 (HBeAg+)或>2000 (HBeAg-) ALT>2×ULN和/或明显的组织学证据;ALT 1~2×ULN和明显的纤维化
    ≤20 000 (HBeAg+)或≤2000 (HBeAg-) ALT<2×ULN,符合以下条件之一:(1)年龄>40岁;(2)肝硬化/HCC家族史;(3)既往曾接受抗病毒治疗;(4)HBV相关肝外表现3)
    >106 (HBeAg+) ALT正常,年龄>40岁,肝组织活检显示明显的坏死性炎症或纤维化
    肝硬化 可检测到 ALT任意水平
    中华医学会
     肝病学分会[8] 2019年 非肝硬化 可检测到 排除其他原因4)所致ALT持续升高(>1×ULN);ALT正常,有下列情况之一:
    (1)肝组织学检查提示明显炎症和/或纤维化(G ≥2和/或S ≥2);(2)有乙型肝炎肝硬化/HCC家族史且年龄>30岁;(3)年龄>30岁,建议肝纤维化无创诊断技术检查或肝组织学检查,存在明显肝脏炎症或纤维化;(4)HBV相关肝外表现3)
    代偿期肝硬化 可检测到 ALT任意水平
    失代偿期肝硬化 任意水平 ALT任意水平
    注:ULN, 正常值上限。1)APASL(2015), ULN: 男30 U/L,女19 U/L; EASL(2017), ULN:40 U/L; AASLD(2018), ULN:男35 U/L,女25 U/L; 中华医学会肝病学分会(2019), ULN:40 U/L。2)肝活检中至重度炎症是指Ishak评分肝脏活动性指数>3/18或METAVIR活动性评分A2或A3。显著纤维化评估:Ishak纤维化分期≥3或METAVIR纤维化评分F ≥2。LSM ≥8 kPa或APRI ≥1.5表示显著纤维化;LSM ≥11 kPa或APRI ≥2.0表示肝硬化。3)HBV相关肝外表现:肾小球肾炎、血管炎、结节性多动脉炎、周围神经病变等。4)ALT升高的其他原因:其他病原体感染、药物或毒物服用史、饮酒史、脂肪代谢紊乱、自身免疫紊乱、肝脏淤血或血管性疾病、遗传代谢性肝损伤、全身性系统性疾病。
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