亚太地区慢性乙型肝炎治疗共识(2012最新版)

自2008年至今,有大量关于慢性HBV感染的自然史和治疗的最新数据不断涌现。其中包括慢性HBV感染的无症状感染者,以社区为基础的队列研究,HBV基因型的作用,非药物诱导的自然HBV变异型毒株,无创性肝纤维化评估方法的应用,HBsAg定量在临床中的应用,更有效的新治疗药物和新治疗方案等等。来自亚太地区的专家审查和评估了相关数据,并共同商讨了近年来报道的最有意义的发现,基于此,对2008年版的亚太地区慢性乙型肝炎治疗共识进行修订,同时对2008年版治疗指南定义的关键词组进行了修订。修订后的指南包括以下几方面内容:一般治疗,肝纤维化评价适应证,何时开始治疗或停药,初始抗病毒治疗药物的选择,如何监测治疗中和治疗后的患者。关于特殊人群的治疗建议中包括了对妊娠妇女,已发生耐药,合并其他病毒感染,肝功能失代偿,接受免疫抑制治疗、化疗,肝移植或肝细胞癌患者的具体治疗建议。

miR-106b-25/miR-17-92 clusters: Polycistrons with oncogenic roles in hepatocellular carcinoma

MicroRNAs are small endogenously expressed RNA molecules which are involved in the process of silencing gene expression through translational regulation.The polycistronic miR-17-92 cluster is the first microRNA cluster shown to play a role in tumorigenesis.It has two other paralogs in the human genome,the miR-106b-25 cluster and the miR-106a-363 cluster.Collectively,the microRNAs encoded by these clusters can be further grouped based on the seed sequences into four families,namely the miR-17,the miR-92,the miR-18and the miR-19 families.Over-expression of the miR-106b-25 and miR-17-92 clusters has been reported not only during the development of cirrhosis but also subsequently during the development of hepatocellular carcinoma.Members of these clusters have also been shown to affect the replication of hepatitis B and hepatitis C viruses.Various targets of these microRNAs have been identified,and these targets are involved in tumor growth,cell survival and metastasis.In this review,we first describe the regulation of these clusters by c-Myc and E2F1,and how the members of these clusters inturn regulate E2F1 expression forming an auto-regulatory loop.In addition,the roles of the various members of the clusters in affecting relevant target gene expression in the pathogenesis of hepatocellular carcinoma will also be discussed.

Acute-on-chronic liver failure in a multi-ethnic Asian city:A comparison of patients identified by Asia-Pacific Association for the Study of the Liver and European Association for the Study of the Liver definitions

AIM To explore the applicability of the Asia-Pacific Association for the Study of the Liver(APASL) and European Association for the Study of the Liver(EASL) guidelines for acute-on-chronic liver failure(ACLF) in profiling patients and determining the outcome.METHODS Patients admitted to a tertiary hospital in Singapore with acute decompensation of liver disease from January 2004to July 2014 are screened for ACLF according to the APASL and EASL criteria. The patients' data(including basic demographics, information about existing chronic liver disease, information about the acute decompensation, relevant laboratory values during admission, treatment, and outcome) are retrospectively analyzed to determine the background, precipitating factors and outcome.RESULTS A total of 458 liver patients is analyzed, and 78 patients with ACLF are identified. Sixty-three patients(80.8%) meet the APASL criteria, 64 patients(82.1%) meet the EASL criteria, and 49 patients(62.8%) fulfilled both criteria. The most common causes of acute liver injury are bacterial infections(59.0%), hepatitis B flare(29.5%), and variceal bleeding(24.4%). The common aetiologies of the underlying chronic disease included hepatitis B(43.6%), alcoholic(20.5%) and cryptogenic(11.5%) liver disease. The overall mortality rate is 61.5%. Increased age, the number of organ failures(as per CLIF-SOFA score), peak creatinine, INR, and amylase levels are associated with increased mortality or the need for liver transplantation. 14.3% of patients undergo liver transplantation with a 100% 1-year survival rate. CONCLUSION Both APASL and EASL criteria have identified ACLF patients with high three-month mortality, but those who fulfill APASL criteria alone have a better survival.

Percutaneous paraumbilical embolization as an unconventional and successful treatment for bleeding jejunal varices

A 48-year-old Indian male with alcoholic liver cirrhosis was admitted after being found unresponsive. He was hypotensive and had hematochezia. Esophagogastroduodenoscopy (EGD) showed small esophageal varices and a clean-based duodenal ulcer. He continued to have hematochezia and anemia despite blood transfusions. Colonoscopy was normal. Repeat EGD did not reveal any source of recent bleed. Twelve days after admission, his hematochezia ceased. He refused further investigation and was discharged two days later. He presented one week after discharge with hematochezia. EGD showed non-bleeding Grade 1 esophageal varices and a clean-based duodenal ulcer. Colonoscopy was normal. Abdominal computed tomography (CT) showed liver cirrhosis with mild ascites, paraumbilical varices, and splenomegaly. He had multiple episodes of hematochezia, requiring repeated blood transfusions. Capsule endoscopy identified the bleeding site in the jejunum. Concurrently, CT angiography showed paraumbilical varices inseparable from a loop of small bowel, which had herniated through an umbilical hernia. The lumen of this loop of small bowel opacified in the delayed phase, which suggested variceal bleeding into the small bowel. Portal vein thrombosis was present. As he had severe coagulopathy and extensive paraumbilical varices, surgery was of high risk. He was not suitable for transjugular intrahepatic porto-systemic shunt as he had portal vein thrombosis. Percutaneous paraumbilical embolization via caput medusa was performed on day 9 of hospitalization. Following the embolization, the hematochezia stopped. However, he defaulted subsequent follow-up.

Up-regulation of micro RNA-210 inhibits proliferation of hepatocellular carcinoma cells by targeting YES1

AIM: To determine the expression of micro RNA-210(mi R-210) in hepatocellular carcinoma(HCC) and to examine its role using HCC cells.METHODS: The expression of mi R-210 was determined in 21 pairs of HCC samples and the corresponding surrounding non-tumor tissues. The effects of mi R-210 on proliferation and cell cycle progression were examined using Hep G2 and Hu H7 cells. Overexpression and inhibition of mi R-210 was achieved by transfection of the cells with mi R-210 mimic or inhibitor. Luciferase reporter constructs were used to identify the mi R-210 interacting site on Yes1. Yes1 expression was examined after mi R-210 transfection,as well as in the HCC samples.RESULTS: mi R-210 was significantly up-regulated by 3.4 fold(P < 0.01) in the tumor samples. The over-expression of mi R-210 significantly reduced cell proliferation compared to the mock-treated cells(68.9% ± 7.4% and 53.6% ± 5.0%,P < 0.05 for the Hep G2 and Hu H7 cells respectively). Analysis of the Hu H7 cells transfected with mi R-210 mimic by flow cytometry showed that the cells took a longer time to reach the G2/M phase. The interaction between mi R-210 and the 3'UTR of the Yes1 transcript was confirmed using a luciferase reporter assay. Over-expression of mi R-210 reduced the expression of Yes1 protein in both Hu H7 and Hep G2 cells. Tumors with a greater than fourfold increase in the expression of mi R-210 showed consistently lower expressions of Yes1 in the tumors.In nocodazole-treated cells with a significant G2/M cell population,Yes1 protein was significantly reduced and pre-inhibition of mi R-210 in Hu H7 cells was able to prevent the reduction of Yes1 protein expression. Knock-down of Yes1 by si RNA also led to reduced cell proliferation(70.8% ± 7.5%,P < 0.05 in the Hu H7 cells).CONCLUSION: Up-regulation of mi R-210 inhibits cell proliferation. Yes1 is a target of mi R-210 and affects cell proliferation in HCC.

Outcome of lamivudine-resistant hepatitis B virus is generally benign except in cirrhotics

AIM： We set to determine factors that determine clinical severity after the development of resistance.METHODS： Thirty-five Asian patients with genotypic lamivudine resistance were analyzed in three groups： 13/35 （37%） were non-cirrhotics with normal pre-treatment ALT （Group IA）, 12/35 （34%） were non-cirrhotics with elevated pre-treatment ALT （Group IB）, and 10/35 （29%） were cirrhotics （Group II）. Patients were followed for a median of 98 wk （range 26-220） after the emergence of genotypic resistance.RESULTS： Group IA patients tended to retain normal ALT. Group IB patients showed initial improvement of ALT with lamivudine but 9/12 patients （75%） developed abnormal ALT subsequently. On follow-up however, this persisted in only 33%. Group II patients also showed improvement while on treatment, but they deteriorated with the emergence of resistance with 30% death from decompensated liver disease. Pretreatment ALT levels and CPT score （in the cirrhotic group） were predictive of clinical resistance and correlated with peak ALT levels and CPT score.CONCLUSION： The phenotype of lamivudine-resistant HBV correlated with the pretreatment phenotype. The clinical course was generally benign in non-cirrhotics. However, cirrhotics had a high risk of progression and death （30%） with the development of lamivudine resistance.

Validation of four Helicobacter pylori rapid blood tests in a multi-ethnic Asian population

AIM: To validate the accuracy of four rapid blood tests in the diagnosis of Helicobacter pylori.METHODS: Consecutive dyspeptic patients scheduled for endoscopy at the National University Hospital,Singapore, were interviewed and had blood drawn for serology. The first 109 patients were tested with BM-test (BM), Pyloriset Screen (PS) and QuickVue (QV), and the next 99 subjects were tested with PS and Unigold (UG).Endoscopies were performed blinded to rapid blood test results and biopsies were taken for culture and rapid urease test. Urea breath tests were performed after endoscopies. The rapid blood test results were compared with four reference tests (rapid urease test, culture,serology, and breath test).RESULTS: The study population composed of 208patients (mean age 43.1 years; range 18-73 years; 119males; 174 Chinese). The number of evaluable patientsfor BM, QV, UG and PS were 102, 102, 95, and 197,respectively. The sensitivity and specificity, respectively were: PS 80.2%, 95.8%; UG 55.9%, 100%; QV 43.3%,100%; BM 67.2%, 97.1%.CONCLUSION: The rapid blood test kits showed high specificity and positive predictive value (97-100%), while sensitivity and negative predictive value ranged widely (43%-80% and 47%-73%, respectively). Among test kits, PS showed the best sensitivity (80%), best negative predictive value (73%) and best negative likelihood ratio (0.207). PS had a specificity of 96%, positive predictive value of 97% and positive likelihood ratio of 19.1.

慢性乙型肝炎治疗开始和停药时机的影响因素

【内容简介】本视频重点介绍慢性乙型肝炎(chronic hepatitis B,CHB)患者治疗开始和停药时机的影响因素。依据血清乙型肝炎病毒(hepatitis B virus,HBV)DNA、丙氨酸氨基转移酶(alanine aminotransferase,ALT)水平和肝脏疾病严重程度,同时需结合年龄、家族史和伴随疾病等因素,综合评估患者疾病进展风险,决定是否需要启动抗病毒治疗。慢性乙型肝炎治疗的总体目标为预防肝硬化、肝功能衰竭和肝细胞肝癌的发生,提高生存率。