乙型肝炎病毒再激活.ppt

乙型肝炎病毒再激活: 一个能够预防的问题 南昌大学第一附属医院 张伦理 Thanks 预先抗病毒治疗的价值 HBsAg-positive patients with NHL treated with CHOP randomized to “preemptive” vs “on-demand” lamivudine Hsu C, et al. Hepatology. 2008;47:844-853. On-demand group: start LAM if ALT 1.5 x ULN Preemptive group: start LAM on Day 1 of CHOP Preemptive antivirals decrease HBV reactivation HBV Reactivation and Hepatitis Flare HBV Reactivationand Jaundice HBV Reactivation and ALT 10 x ULN Death (After ChemoTx) 100 80 60 40 20 0 HBsAg Patients (%) 48 8 36 0 20 0 0 8 如何选择抗病毒治疗方案与监测 治疗方案的选择受 HBV DNA 水平的影响 HBV DNA 2000 IU/mL: any therapy can be used (including lamivudine) HBV DNA 2000 IU/mL: entecavir or tenofovir 治疗方案的选择受治疗时间长短的影响 12 mos: entecavir or tenofovir HBV DNA and ALT 应该每3个月检测一次 EASL. J Hepatol. 2009;50:227-242. Lok AS, et al. Hepatology. 2009;50:661-662. 抗病毒治疗的时间 什么时间开始 Ideally before or together with chemotherapy Do not delay start of chemotherapy 什么时间停止 If baseline HBV DNA 2000 IU/mL: high risk of withdrawal flare Continue therapy as for chronic HBV infection If baseline HBV DNA 2000 IU/mL 6-12 mos after end of chemotherapy 每月检测HBVDNA和ALT监测停药后肝炎是否复发 EASL. J Hepatol. 2009;50:227-242. Lok AS, et al. Hepatology. 2009;50:661-662. 总结 HBV再激活的诱因较多 HBsAg 检测便宜，应该在需化疗或免疫调节治疗的病人中广泛开展HBsAg筛选 如果HBsAg阳性，化疗或其他免疫调节治疗后，HBV再激活易于发生 单纯抗HBc阳性者，在使用Rituximab和骨髓或干细胞移植时，有可能发生HBV再激活，应该在治疗过程中严密监测HBV-DNA和HBsAg 有效地抗乙肝病毒治疗可以预防HBV再激活，但是必须尽早开始。应在化疗前或同时进行！ So as most of you are aware, hepatitis B is a major global public health problem. * * If you look around the world, there are 350 million people who are chronically infected, and what we mean by that is that they are HBsAg positive and have replicating virus. However, if you look at the larger population of people who have been exposed to this virus, over 2 billion people have evidence of either past or current infection with hepatitis B. And I’ll discuss shortly the idea that these people have cleared their hepatitis B infection is somewhat of a misnomer, and I