McMahon Brian J
Liver Disease and Hepatitis Program, Alaska Native Medical Center, Anchorage, Alaska 99508, USA.
Am J Med. 2008 Dec;121(12 Suppl):S45-52. doi: 10.1016/j.amjmed.2008.09.028.
In the past 2 years, evidenced-based guidelines and statements on screening, diagnosis, and management of hepatitis B virus (HBV) from several organizations and experts have been published. The purpose of this article is to take the recommendations from these documents and help guide clinicians--whether they are primary care providers, hepatologists, gastroenterologists, or public health workers--about how to incorporate these guidelines into practice. The first task is for all providers to be involved in identifying persons with chronic HBV infection (CHB). New recommendations from the Centers for Disease Control and Prevention (CDC) advocate screening for the HBV in those at highest risk, especially persons from countries where HBV is endemic. Using information from the clinical and laboratory evaluation of the patient infected with HBV, especially the hepatitis B e antigen/antibody status, clinicians can classify the patient into 1 of the 4 phases of HBV infection. Because CHB is a dynamic process and patients can move from inactive to active infection status, and vice versa, all patients must be followed with alanine aminotransferase (ALT) and aspartate aminotransferase monitoring every 3 to 12 months for life. Those with elevated ALT and HBV DNA levels (>2,000 IU/mL) should be referred to a specialist for evaluation for possible treatment. Patients selected for antiviral therapy with nucleoside analogues should be followed every 3 to 6 months to detect emergence of antiviral resistance to the agent chosen. In addition, alpha-fetoprotein should be tested and ultrasound performed on all men aged >40 years and women >50 years of age to detect any hepatocellular carcinoma (HCC) in an early stage. Algorithms are included for primary care providers providing information on initial evaluation and management and referral of persons with CHB, and for specialists evaluating and treating HBV. Implementing steps to identify, follow, refer, and treat appropriately persons with CHB infection by all primary care and specialist healthcare providers can have a major impact on reducing the occurrence of HCC and cirrhosis in infected persons.
在过去两年中，多个组织和专家发布了关于乙型肝炎病毒（HBV）筛查、诊断及管理的循证指南和声明。本文旨在采纳这些文件中的建议，帮助指导临床医生——无论是初级保健提供者、肝病专家、胃肠病学家还是公共卫生工作者——如何将这些指南应用于实践。首要任务是让所有医疗提供者参与识别慢性HBV感染（CHB）患者。美国疾病控制与预防中心（CDC）的新建议提倡对高危人群进行HBV筛查，尤其是来自HBV流行国家的人群。利用对HBV感染患者进行临床和实验室评估所获得的信息，特别是乙肝e抗原/抗体状态，临床医生可将患者归类为HBV感染的四个阶段之一。由于CHB是一个动态过程，患者可能从非活动性感染转变为活动性感染状态，反之亦然，因此所有患者必须终身每3至12个月监测丙氨酸氨基转移酶（ALT）和天冬氨酸氨基转移酶。ALT和HBV DNA水平升高（>2000 IU/mL）的患者应转诊至专科医生处进行评估，以确定是否需要治疗。选择使用核苷类似物进行抗病毒治疗的患者应每3至6个月进行随访，以检测对所选药物是否出现抗病毒耐药性。此外，所有40岁以上男性和50岁以上女性均应检测甲胎蛋白并进行超声检查，以便早期发现任何肝细胞癌（HCC）。文中还包含了针对初级保健提供者的算法，这些算法提供了关于CHB患者初始评估、管理及转诊的信息，以及针对评估和治疗HBV的专科医生的算法。所有初级保健和专科医疗提供者采取适当的步骤来识别、随访、转诊和治疗CHB感染患者，对于减少感染者中HCC和肝硬化的发生可能会产生重大影响。
