慢性乙肝的评估与治疗课件幻灯.pptVIP

慢性乙肝的评估与治疗 Prof Eugene R. Schiff, M.D.University of Miami, Florida, USA美国佛罗里达州迈阿密大学 1、慢性乙肝 – 临床特点 3、慢性乙肝的自然史 4、慢性乙肝感染的自然史 5、慢性乙肝: 定义 6、慢性乙肝病程进展的预测因子 7、慢性乙肝预后改善的预测因子 8、对乙型肝炎严重程度的评估 9、慢乙肝的治疗 10、乙型肝炎– 诊断指标 11、未接触过乙肝 12、HBV DNA检测的敏感性 13、血清 HBV DNA 检测值 14、急性乙肝 病毒学指标均阳性，但持续时间 6 个月 HBsAg + HBeAg + HBV DNA + 对病毒存在部分免疫反应 Anti-HBc + Anti-HBs - Anti-HBe - 15、急性乙肝痊愈的典型血清学过程 16、慢乙肝病毒复制的证据 17、慢性乙肝病毒感染病程的典型血清学表现 18、如何监测? 19、拉米夫定治疗期间ALT升高的可能原因 20、出现YMDD 变异株是否会导致血清 ALT 升高? 21、治疗3年中的血清ALT 升高 22、YMDD变异与临床失效患者的治疗选择 23、在YMDD变异的乙肝病人中继续拉米夫定治疗的益处 24、总结 Key message: YMDD variant HBV is detected using tests based on the polymerase chain reaction (PCR) and may therefore be found in patients who are HBV DNA negative by the less sensitive solution hybridisation assays that are used routinely in clinical practice. Explanation: In routine clinical practice, serum HBV DNA is commonly assayed by solution hybridisation (e.g. Chiron assay). This type of test has a sensitivity that is usually sufficient for identifying patients with higher levels of viraemia associated with increased risk of disease progression. In contrast, tests based on the polymerase chain reaction (PCR) are approximately 1,000-fold more sensitive and can often detect HBV in serum even after HBeAg or HBsAg seroconversion. The clinical significance of viraemia detectable only by PCR is unknown. PCR methodology is used to test for the presence of YMDD variant HBV. It is therefore possible to detect the presence of YMDD variant HBV in the serum of a patient that tests negative for HBV DNA by less sensitive routine assays. Reference: Zeuzem S, Workshop on Management of hepatitis B: 2000, NIH Bethesda, US 30 31 潜伏期: 平均 60–90 天 范围 45–180 天 临床发病期 (黄疸): 5 岁, 10% 5 岁, 30%–50% 急性病例死亡率: 0.5%–1% 慢性感染: 5 岁, 30%–90% 5 岁, 2%–10% 慢性肝病引起的过早死亡: 15%–25% HBeAg 细胞核 细胞浆 (++ ~) (-) (+++) 细胞膜 (++ ~) HBsAg/前S 细胞膜 细胞浆(++ ~) 细胞浆 (+++) (+++) 细胞膜 (++ ~) HLA-1 (-) (++) (++) 病期 免疫耐受 免疫清除 晚期 / 残余 再活动 前-C 区变异 HBV-DNA HBeAg