轻度慢性乙型肝炎合并肺结核患者抗病毒治疗82病例对照研究

Antiviral treatment of mild chronic hepatitis B patients with tuberculosis: A controlled study

目的观察轻度慢性乙型肝炎(chronic hepatitis B,CHB)合并肺结核(pulmonary tuberculosis,PTB)患者的应用恩替卡韦抗乙型肝炎病毒(hepatitis B virus,HBV)的临床治疗效果.方法选取2010-01/2016-12收治的临床诊断为轻度CHB[谷丙转氨酶(alanine transaminase,ALT)≤80 IU/L,HBV DNA升高超过检测下限]同时合并PTB的患者82例,做肝活检后随机分为"抗病毒+抗痨组"和单独"抗痨组"各41例.前者应用恩替卡韦抗HBV,2 wk后联合2HREZ/4HR抗痨方案;后者直接单独应用2HREZ/4HR,疗程均为6 mo.两组疗程中常规预防性口服水飞蓟宾、复方甘草酸苷等护肝药物.结果82例肝活检显示,炎症程度G1级22例,占26.8%,G2-3级73.2%,纤维化程度≥S2 49例,占59.8%;抗病毒组患者治疗前及治疗后4、12、24 wk ALT、总胆红素水平稳定,其参数变化无统计学意义,但治疗后HBV DNA下降明显,与治疗前相比,治疗后4、12、24 wk均有统计学差异(P<0.05),与未抗病毒组HBV DNA水平比较,治疗后4、12、24 wk亦有明显差异(P<0.05);两组患者于抗痨治疗6 m o疗程结束时比较,在HBV DNA阴转率(95.1%vs 0.0%)、肝损害发生率(14.6%vs 46.3%)、因不良反应未按时完成抗痨疗程,中途被迫中断抗痨比例(9.8%vs 34.2%)等方面,均有显著差别(P<0.05),抗病毒组优于单纯抗痨组.结论临床诊断的轻度CHB合并PTB患者,ALT等血清生化学指标难以如实体现合并感染后的肝脏炎症情况;即使ALT水平和肝活检结果未达到《慢性乙型肝炎防治指南》要求,预先应用恩替卡韦等强效抗HBV药物干预,对降低患者应用抗痨药物的肝脏不良反应发生几率、抑制HBV DNA的复制、减少抗痨中断、提高患者的抗痨依从性和治疗效果亦有良好作用.

AIM To observe the clinical efficacy of entecavir against hepatitis B virus（HBV） in patients with mild chronic hepatitis B（CHB） and pulmonary tuberculosis（PTB）.METHODS Eight-two cases mild CHB patients with PTB were chosen between January 2010 and December 2016. After liver biopsy, they were randomly divided into an antiviral treatment group（41 cases） and an antituberculosis therapy group（41 cases）. The antiviral treatment group was treated with entecavir, and after 2 wk, it was combined with 2 HREZ/4 HR for antituberculosis treatment. The antituberculosis therapy group was treated with 2 HREZ/4 HR only. The course of treatment in both groups was 6 mo. Oral silybin and compound glycyrrhizin were given in both groups. After treatment, therapeutic efficacy and safety were compared between the two groups.RESULTS All the 82 cases underwent liver biopsy, which showed that 22（26.8%） cases had G1 grade inflammation and 49（59.8%） cases had a fibrosis level ≥ S2. The levels of ALT and Tbil were comparable between after andbefore treatment in the two groups. However, the HBV DNA significantly declined at 4, 12, and 24 wk after antiviral treatment（P〈0.05）, and HBV DNA in the antiviral treatment group was significantly lower than that in the antituberculosis therapy group. After treatment, HBV DNA negative conversion rate（95.1% vs 0%）, liver damage（14.6% vs 46.3%）, and the rate of discontinuing antituberculosis treatment due to adverse reactions（9.8% vs 34.2%） were significantly better in the antiviral treatment group than in the antituberculosis therapy group（P〈0.05）. CONCLUSION For mild chronic hepatitis B patients with tuberculosis, entecavir treatment can reduce the incidence of liver adverse reactions to antituberculosis treatment, decrease HBV DNA level, reduce the discontinuation of antituberculosis therapy, and improve the clinical compliance to antituberculosis treatment.