1--乙肝肝硬化抗病毒治疗的现状和思考(河南年会100925).ppt

失代偿性乙型肝炎肝硬化抗病毒治疗的现状与思考 上海长海医院感染科 万谟彬 2010.9.25 郑州 代偿性乙型肝炎肝硬化是HBV感染相关疾病中的特殊人群，但其抗病毒治疗指征、药物选择、疗程、治疗终点、停药指征等均和慢性乙型肝炎普通人群一致，并无特殊，只是抗病毒治疗的指征更宽，停药指征应更严。这里不做讨论，而重点讨论失代偿乙肝肝硬化的抗病毒治疗的有关问题。 核苷（酸）类似物治疗失代偿性乙型肝炎肝硬化的现状 早期探索：药物、疗效、安全 当前热点：更优治疗方案选择 初步印象：“五不够” 基本共识：指征、目标、策略 核苷（酸）类似物治疗失代偿性乙型肝炎肝硬化的现状 早期探索：药物、疗效、安全 当前热点：更优治疗方案选择 初步印象：“五不够” 基本共识：指征、目标、策略 2001：Perrillo等用拉米夫定治疗等待肝移植的77例失代偿肝硬化患者，病毒等各项指标好转，且4年生存率70%，明显高于 2项先期报道的约60%和30%。 Perrillo and colleagues from multiple liver transplant centers throughout North America treated 77 liver transplant candidates with end-stage chronic hepatitis B with lamivudine (100 mg daily). No control group was used, but results were compared to outcomes in two previously published studies of decompensated cirrhosis due to hepatitis B. HBV DNA levels decreased on lamivudine therapy, but levels were not reported. Alanine aminotransferase (ALT) values decreased and became normal in more than half of patients with elevations before treatment. Average serum bilirubin, albumin, and prothrombin times improved with treatment. The 4-year survival rate among amivudine-treated patients was 70%, which was higher than historical cohorts (~60% and 30%). Lamivudine was well tolerated. Antiviral esistance developed in a proportion of patients, and appearance of resistance was generally followed by reversal of the virological and clinical bene?t. 2003：Schiff等报道阿德福韦酯治疗等待肝移植的肝硬化患者128例，48周时HBV DNA下降4.1log、ALT复常率76%、Child-Pugh稳定或改善90%以上、1年存活率84%。肝移植率43%，36%等待移植，21%不需移植，5%死亡。 In a third study, Schiff and colleagues from multiple clinical centers in North America, Europe, and Asia treated 128 patients with HBV-related cirrhosis awaiting liver transplantation with adefovir (10mg daily). Therapy was associated with signi?cant declines in HBV DNA levels (median decline of 4.1 log10 by week 48) and serum aminotransferase levels (normal ALT in 76% by week 48). The Child-Pugh score stabilized or improved in more than 90% of patients and the 1-year survival rate was 84