对慢性乙型肝炎及肝硬化患者的核苷(酸)类药物耐药位点的分析

Profile of Hepatitis B Virus Resistance Mutations against Nucleos( t) ide Analogue Treatment in Chronic Hepatitis B( CHB) Patients and HBV- Liver Cirrhosis Patients

目的 研究接受核苷（酸）类似物抗病毒治疗、出现病毒学突破后的慢性乙型肝炎、肝硬化患者血清乙型肝炎病毒（HBV）P区基因序列突变率,突变形式及用药情况,为评估病情进展和实施下一步抗病毒治疗方案提供较为全面的信息.方法 选取浙江中医药大学附属第六医院2009年3月～2012年10月447例接受核苷（酸）类似物抗病毒治疗、出现病毒学突破后的慢性乙型肝炎、肝硬化患者为研究对象,采用基因直接测序法,对其血清HBV P区基因PCR扩增产物进行测序,分析各个耐药位点,同时搜集相关用药史进行回顾性分析.结果 在447例病例中存在位点突变者227例（50.8％）,共存在30种变异形式,变异形式以M204I、L180M＋ M204V、L180M＋ M204I三者居多.其余种类复杂多样,大多以联合突变形式出现;耐药药物的使用及产生的耐药位点基本一致;主要的变异位点集中发生在M204I和L180M,余均较为分散.且经统计分析,乙型肝炎及肝硬化两总体的突变率有统计学差异.结论 对核苷（酸）类似物抗病毒治疗中出现病毒学突破的慢性乙型肝炎及肝硬化患者血清中HBVP区基因耐药位点的分析研究对合理用药以及发生耐药后及时调整治疗方案有重要的作用.

Objective To analyze the profile of hepatitis B virus （HBV） resistance mutations against nucleos （t） ide analogues （NAs） treatment in patients with chronic hepatitis B （CHB） or with HBV-liver cirrhosis for more comprehensive information to assess disease progress and to implement further antiviral treatment step.Methods A total of 447 patients with chronic hepatitis B or HBV-liver cirrhosis after virological breakthrough aganist antiviral nucleos（t） ide treatment from the sixth affiliated hospital of Zhejiang Chinese Medical University from March 2009 to October 2012 were selected.we used genes direct sequencing method to analyse their PCR products of serum HBV P gene and the resistant sites and the relevant medical history was reviewed.Results We found the mutation rate was 50.8％,and there were 30 kinds of mutation forms in which M204I,L180M ＋ M204V and L180M ＋ M204I were accounting for 32.2％,18.5％ and 16.7％.The rest were diverse and most of all were united mutant forms.The use of the drug and its generated resistance locies were basically identical.The main mutant sites were M204I and L180M and the rest dispersed.We found that the mutant sites mutation rate of two samples was not different but a few major differences in mutation sites were statistically significant by analysing the cases with hepatitis B and HBV-liver cirrhosis.Conclusion It plays a very important role in rational drug use and adjusting antiviral treatment that the study of HBV P area mutations of antiviral therapy of chronic hepatitis B and liver cirrhosis patients after virological breakthrough.