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本帖最后由 StephenW 于 2012-2-8 12:34 编辑
Management of Acute Hepatitis B Virus Infection
The symptoms and course of acute hepatitis B virus (HBV) infection depends strongly on the age at the time of infection.[Liaw 2009a] Acute hepatitis B is usually subclinical in neonates, whereas up to one third of adults may experience symptoms.[McMahon 1985] Early symptoms include influenzalike symptoms, gastrointestinal symptoms, and fatigue. When these symptoms subside, darkening of urine, pale stool, and jaundice may be observed. Physical examination findings are nonspecific, and may include mild enlargement and slight tenderness of the liver, and mild splenomegaly.
The diagnosis of acute HBV infection is based on the presence of hepatitis B surface antigen (HBsAg) and IgM-antibodies to hepatitis B core antigen (IgM-anti-HBc) in serum.[Lok 2009] During the initial phase, patients may also be positive for hepatitis B e antigen (HBeAg), and high levels of HBV DNA may be detected. In patients with self-limiting disease, antibodies to HBsAg (anti-HBs) develop, but there may be a window period where both anti-HBs and HBsAg are negative, leaving anti-HBc the only detectable marker. If HBsAg is not cleared from serum, chronic hepatitis B infection is diagnosed after documented positivity for 6 months.[Lok 2009; EASL 2009]
Treatment is generally not indicated for acute HBV infection because most patients (> 95%) recover spontaneously.[Liaw 2009a] Therefore, management of acute hepatitis B infection is typically supportive, and close monitoring may help early identification of fulminant hepatitis with liver failure. However, treatment is indicated for patients with fulminant hepatitis B according to the American Association for the Study of Liver Diseases (AASLD) (Management Guidelines)[Lok 2009] and the European Association for the Study of the Liver (EASL) (Management Guidelines).[EASL 2009] For such patients, the AASLD guidelines recommend lamivudine or telbivudine if the duration of treatment is expected to be short,[Lok 2009] and the EASL guidelines state that lamivudine may be used.[EASL 2009] According to AASLD, if the duration of therapy is expected to be long term, entecavir is preferred due to the risks of resistance associated with lamivudine and telbivudine therapy.[Lok 2009] These recommendations are based largely on studies that show that, although lamivudine therapy does not appear to increase the probability of HBsAg clearance,[Yu 2010; Kumar 2007] treatment reduces mortality in patients with severe acute hepatitis B.[Yu 2010] Indeed, in one study of 80 patients with acute HBV infection receiving either lamivudine or no therapy, mortality was significantly higher in the control group at 25.0% vs the lamivudine group at 7.5% (P = .034).[Yu 2010] Interferon therapy is contraindicated in patients with acute HBV infection because of the high rate of adverse effects and the risk of worsening hepatitis.[Lok 2009; EASL 2009] Tenofovir is not an optimal treatment choice due to its potential for nephrotoxicity. Treatment of acute HBV infection should be continued until HBsAg clearance.[Lok 2009]
急性B型肝炎病毒感染的管理
急性B型肝炎病毒（HBV）感染的症状和当然取决于年龄的强烈感染的时间。[廖2009a的急性B型肝炎通常是亚临床新生儿，而多达三分之一的成年人可能会遇到的症状。麦克马洪1985]早期症状包括流感样症状，胃肠道症状和疲劳。当这些症状消退，尿变黑，脸色苍白大便，黄疸，可观察到。体检结果是非特异性的，并可能包括轻度肿大和肝脏轻微压痛，轻度脾肿大。
急性HBV感染的诊断依据是血清中乙肝表面抗原（HBsAg）和IgM抗体的存在乙型肝炎核心抗原（IgM型抗-HBc）。[乐2009年在最初阶段，患者也可乙型肝炎e抗原（HBeAg），乙型肝炎病毒DNA水平高阳性可能被检测到。自限性疾病患者，乙肝表面抗原（抗-HBs）抗体的发展，但也有可能是一个窗口期，抗-HBs和HBsAg阴性，离开抗-HBc检测的标记。如果不从血清中清除乙肝表面抗原，慢性乙型肝炎病毒感染的诊断[乐2009年欧洲肝病学会2009] 6个月后记录阳性。
治疗急性HBV感染一般不表示，因为大多数患者（> 95％）自发地恢复。廖2009a的，因此，急性乙型肝炎病毒感染的管理是典型的支持，并密切监测可能有助于重型肝炎肝功能衰竭的早期识别。然而，治疗暴发性乙型肝炎患者表示，根据美国肝病研究协会（AASLD）（管理指引）[乐]和欧洲肝脏研究协会（EASL）（管理指引） [欧洲肝病学会2009]对于此类患者，肝病学会的指引建议拉米夫定或替比夫定治疗期间，如果预计要短，[乐2009] [欧洲肝病学会2009欧洲肝病学会的指引，拉米夫定可使用的状态。据肝病学会，如果治疗期间预计将是长期的，恩替卡韦是首选由于拉米夫定和替比夫定治疗的抵抗有关的风险。[乐2009]这些建议主要是根据研究显示，虽然拉米夫定治疗不会出现HBsAg清除的概率增加，[羽2010年库马尔2007]治疗急性重症肝炎患者的死亡率降低B. [羽2010]事实上，在接受任何拉米夫定或无治疗80例急性HBV感染患者的一项研究中，死亡率为显着高于在对照组与拉米夫定组的25.0％，7.5％（p = .034）。[羽2010]干扰素治疗的禁忌，在急性HBV感染的患者，因为率高的不利影响和恶化的风险肝炎[乐2009年欧洲肝病学会2009]。泰诺福韦是不是一个最佳的治疗方法的选择，由于其潜在的肾毒性。急性HBV感染的治疗，应继续下去，直至HBsAg清除。[乐2009]
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发表于 2012-2-8 12:11
