PCR产物直接测序法检测乙肝病毒耐药位点的临床研究

Clinical research about HBV resistance by direct PCR sequencing

目的总结核苷(酸)类药物[nucleos(t)ide analogue,NA]长期治疗应答不佳患者的临床特征,便于在耐药检测前或不具备耐药检测条件时对患者的耐药情况进行初步判断,指导治疗。方法使用直接测序法对89例NA相关耐药的慢性乙型肝炎(chronichepatitisB,CHB)患者进行检测,分析其耐药变异位点,总结耐药患者的临床特征。结果 89例长期使用NA治疗应答不佳的CHB患者的耐药位点检测阳性率明显高于未用药的对照组(44.9%vs.6.7%,P<0.001)。拉米夫定(lamivudine,LAM)耐药相关病例的耐药位点检测阳性率为45.0%。阿德福韦酯(ade-fovirdipivoxil,ADV)耐药相关病例的耐药位点检测阳性率为20.0%。ADV相关耐药位点检测阳性组应用ADV的疗程明显长于阴性组[(23.82±14.13)个月vs.(7.79±11.74)个月,P<0.001]。发生病毒学突破(或反弹)组耐药位点检测阳性率明显高于原发无应答组(58.33%vs.29.27%,P=0.006)。LAM治疗失败ADV再治疗患者比ADV初治者耐药检出率高,具有显著性差异(42.86%vs.11.54%,P=0.010)。多药组的耐药检出率明显高于单药组(62.75%vs.21.05%,P<0.001),且多位点联合耐药检出率高(P=0.004)。结论长期NA治疗应答不佳患者耐药人群的临床特征是:多药使用者、病毒学突破(或反弹)者、长疗程ADV用药者。了解这些高危人群的特点对于在耐药检测前或不具备耐药检测条件时对患者的耐药情况进行初步判断,进而挽救治疗具有指导意义。

Objective To realize the clinical features of the patients with poor response to drug in long-term treatment of nucleos （t）ide analogues （NA） in order to predict initially drug-resistance before detecting or with no detecting conditions and guide clinical treatment. Methods Eighty-nine clinical cases were analyzed about NA-resistance by direct PCR sequencing to conclude the specific clinical features of patients with poor drug response in long-term NA treatment. Results Compared with non-treatment group,NA treatment group expressed a higher positive rate of HBV resistance variation locus （44.9% vs 6.7%,P 〈 0.001）. In lamivudine（LAM） related resistance cases, the positive rate was 45.0%. In adefovir dipivoxil （ADV） related resistance cases, the positive rate was 20.0%. In the group of ADV reduced variation, positive ones obviously obtained longer treatment, it had significant difference （P 〈 0.001）. Comparing with initial treatment group of non-response, positive rate of resistant detection in group of virology breakthrough （rebound） was quite higher with significant difference（P = 0.006）. Comparing with ADV initial treatment group, group with ADV retreatment on the basis of LAM treatment failure was easy to detect variation, with significant difference （P = 0.010）. Resistance in multiple-drug treatment was obviously higher than singal drug,especially multiple-sites variation （P 〈 0.001 ,P = 0.004）. Conclusion The specific clinical features of long-term NA treatment patients are multiple-drug treatment,virological breakthrough （viral rebound） and long-term ADV treatment. In view of the unpopular evolved of direct PCR sequencing, comprehensive understanding of the specific clinical features is of importance to initial judgment and rescued treatment without detections.