慢性乙型肝炎的规范化治疗特殊人群抗病毒治疗.ppt

化疗和免疫抑制剂治疗的HBV患者的特点 HBV再活动危险高： CHB患者在进行癌症化疗或免疫抑制剂治疗期间，HBV再活动伴失代偿的发生率为20-50% HCC患者经动脉化疗栓塞后的HBV再活动率为34% 血清HBV DNA↑，ALT ↑ 大多数情况下肝炎的突发为无症状性，但临床可观察到突发黄疸、甚至肝功能失代偿和死亡 通常出现在化疗周期的头2~3个周期 AASLD 2009; EASL 2009; APASL 2008 化疗期间HBV再活动自然史 Lau GKK. Hepatol Int (2008) 2:152–162 化疗 LAM预先治疗过程中HBV DNA和ALT变化趋势 肝衰 慢性肝炎 急性 肝炎 血清HBV DNA峰值的出现与肝炎发生的时间间隔是可变的 适应症 无论HBsAg阳性者的HBV DNA载量如何，ALT是否正常 应用免疫抑制剂或细胞毒性药物治疗前2～4周（2010指南1W）均应用核苷（酸）类似物预防治疗 HBsAg阴性、HBcAb阳性者，若需长期或大量免疫抑制剂治疗时，密切监测HBsAg及HBVDNA 药物的选择 预防用药应选择抑制HBV DNA作用迅速的药物，如LAM、LdT与ETV 如预防用药时间＞12个月，建议选用耐药发生率较低的药物（Ⅲ），如小于12月可选用LAM（指南2010） 不建议IFN α,具有骨髓抑制作用（Ⅱ） 抗HBV治疗疗程 在化疗和免疫抑制剂治疗停止后，应根据患者病情决定停药时间 (II-1, II-3)： 对于基线HBV DNA＜2 000 IU/mL的患者，在完成化疗或免疫抑制剂治疗后，应当继续治疗6个月（Ⅲ）； 基线HBV DNA水平较高（＞2 000 IU/mL）的患者，应当持续治疗到和免疫功能正常慢性乙型肝炎患者同样的停药标准（Ⅲ） This slide illustrates how the course of hepatitis B infection can progress, with varying outcomes. In the liver, acute infection (short term infection) with hepatitis B causes the body to mount an immune response to get rid of the virus. The immune system tries to clear the virus by destroying HBV infected liver cells. In some people the immune response succeeds - - the virus along with infected liver cells are completely destroyed and the patient makes a complete recovery (resolution.) However in other HBV-infected people, the immune response to the infection is insufficient to get rid of the virus for many months / years or not at all - - slowly destroying more and more infected liver cells as the virus spreads (long-term infection). This slow persistent destruction of liver cells by the immune system can lead to fibrosis, cirrhosis and even liver cancer. People infected with HBV whose immune systems cannot get rid of the virus are referred to as chronic HBV carriers. Chronic HBV carriers can pass the virus to others. In the liver, acute infection with hepatitis B virus causes the body to mount an immune response to get rid of the virus. Acute hepatitis is a short-term infection, in which the body’s immune