Treat-all:部分应答和低病毒血症的挑战  

Treat-all: challenges of partial response and low-level viremia

作　　者：刘智泓[1] 郝新 侯金林[1] Liu Zhihong;Hao Xin;Hou Jinlin(Department of Infectious Diseases and Hepatology Unit,Nanfang Hospital,Southern Medical University,Institutes of Liver Diseases Research of Guangdong Province,Guangzhou 510515,China)

机构地区：[1]南方医科大学南方医院感染内科暨肝病中心、广东省肝脏疾病研究所,广州510515

出　　处：《中华肝脏病杂志》2023年第3期242-246,共5页Chinese Journal of Hepatology

基　　金：广州市基础与应用基础项目 (SL2022A04J01917)。

摘　　要：我国《慢性乙型肝炎防治指南(2022年版)》已在近期更新。基于我国慢性HBV感染人群的年龄分布和感染途径,本次更新的治疗适应证几乎意味着全面治疗(Treat-all)策略的推行。虽然以乙型肝炎表面抗原(HBsAg)和乙型肝炎病毒(HBV)DNA同时阴性作为停药标准已被普遍接受多年,但HBsAg和HBV DNA双阳性即启动抗病毒治疗的策略却一直存在争议。造成启动和终止治疗标准不统一的原因众多,但近年来随着治疗费用的不断下降,对患者管理的周期不断延长,以及未治疗人群预后不佳的证据日益积累,学界开始反思并逐步支持全面治疗的策略。本次指南更新也意味着慢性HBV感染的治疗,走向了"大道至简"的新方向。在推广Treat-all策略的过程当中,我们仍需要未雨绸缪,提前防范新策略可能带来的问题。其中,由于纳入大量丙氨酸转氨酶正常或低水平的患者,治疗后应答不佳或低病毒血症的问题可能会日益凸显。考虑到已有证据提示低病毒血症也会增加患者的肝细胞癌风险,我们需要做好监测,并进一步探索优化治疗低病毒血症的方案。The recently updated"Guidelines for the Prevention and Treatment of Chronic Hepatitis B"in China have brought about significant changes.The new treatment indications almost mandate the implementation of a Treat-all strategy for the chronically HBV-infected population in China.While simultaneous negativity for hepatitis B surface antigen(HBsAg)and hepatitis B virus(HBV)DNA has long been an accepted criterion for treatment discontinuation,there has been controversies over the initiation of treatment criteria starting with HBsAg and HBV DNA positivity.Despite the inconsistent treatment criteria,the academic community has started supporting treat-all strategies in recent years due to the decreasing cost of treatment,prolonged management duration,and growing evidence of poor outcomes in untreated populations.Therefore,this update to the Chinese HBV guidelines represents a new direction that suggests"The greatest truths are the simplest."However,in the process of rolling out the Treat-all strategy,we must remain cautious of possible issues arising from the new strategy.Among them,the problem of partial response or low-level viremia following treatment may become more prominent due to the inclusion of a significant number of patients with normal or low levels of alanine transaminase.As existing evidence suggests that low-level viremia increases the risk of HCC in patients,it is essential to monitor and explore optimal therapeutic options for these patients.

关 键 词：慢性乙型肝炎 部分应答 低病毒血症 全面治疗策略 治疗适应证 

分 类 号：R512.62[医药卫生—内科学]