从慢性乙型肝炎病毒感染分期角度对扩大抗病毒治疗适应证的思考

Considerations on expanding the indications for antiviral therapy from the perspective of staging of chronic hepatitis B virus infection

根据乙型肝炎病毒(HBV)血清学标志物、HBV DNA、丙氨酸转氨酶和肝脏病理学结果,可将慢性HBV感染者分为免疫耐受期、免疫清除期(HBeAg阳性免疫活动期)、免疫控制期(非活动期)和再活动期(HBeAg阴性免疫活动期)。当不符合上述4个分期标准时,即为不确定期慢性HBV感染。按照我国"指南"推荐意见,伴丙氨酸转氨酶升高的慢性HBV感染者在排除其他原因所致的丙氨酸转氨酶升高后,均推荐抗HBV治疗。因此免疫清除期和再活动期慢性HBV感染者已经包含在抗HBV治疗适应证人群中,扩大适应证主要针对这两期以外的其他感染者:免疫耐受期、免疫控制期和不确定期感染者。其中,尤其是不确定期感染者病情进展风险相对高,可能获益于抗病毒治疗。

Patients with chronic(hepatitis B virus,HBV)infection can be divided into immunotolerant,immunoclearance(HBeAg-positive,immune-active),immunocontrol(inactive),and reactivation(HBeAg-negative,immune-active)phases according to HBV serological markers,HBV DNA,alanine aminotransferase,and liver pathology results.Chronic HBV infection is considered indeterminate when the above four phasing criteria are not met.The Chinese"Guidelines"recommend antiviral B treatment for chronic HBV-infected patients with elevated alanine aminotransferase levels after excluding other potential causes.As a result,patients with chronic HBV infection in the immunoclearance and reactivation phases are included in the indication population for antiviral therapy,and the expanded indications are mainly for other infected individuals beyond these two phases:immunotolerant,immunocontrol,and indeterminate.Antiviral therapy may benefit individuals in an indeterminate phase,because they are at a relatively high risk of disease progression.