Wong Vincent Wai-Sun, Chan Henry Lik-Yuen
Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China.
J Gastroenterol Hepatol. 2009 Jul;24(7):1179-86. doi: 10.1111/j.1440-1746.2009.05924.x.
Severe acute exacerbation is a unique presentation of chronic hepatitis B characterized by very high alanine aminotransferase level accompanied by jaundice and hepatic decompensation. The underlying pathogenesis is likely related to excessive immune clearance, which may be related to the genotype of hepatitis B virus. The mortality is very high once hepatic encephalopathy develops, but some patients can recover to almost normal liver function in contrast to patients with end-stage liver cirrhosis. This condition should be differentiated from acute hepatitis B and other causes of acute hepatitis must be excluded. Conventional prognostic systems may not be applicable to severe acute exacerbation of chronic hepatitis B. In general, patients who have thrombocytopenia, hyperbilirubinemia and coagulopathy have a higher risk of mortality regardless of the serum alanine aminotransferase levels. There is no evidence that lamivudine treatment can reduce the short-term mortality of severe acute exacerbation. However, patients with severe acute exacerbation tend to have a higher rate of maintained virological response, higher rate of hepatitis B e antigen seroconversion and low rate of drug resistance on extended lamivudine treatment as compared to other chronic hepatitis B patients. Virological relapse and severe hepatitis reactivation is common after treatment cessation and therefore long-term antiviral treatment is recommended. Liver transplantation, particularly living donor liver transplantation, should be considered for patients who develop hepatic failure secondary to severe acute exacerbation.
重度急性加重是慢性乙型肝炎的一种独特表现，其特征为丙氨酸氨基转移酶水平极高，并伴有黄疸和肝失代偿。潜在的发病机制可能与过度免疫清除有关，这可能与乙型肝炎病毒的基因型有关。一旦发生肝性脑病，死亡率会非常高，但与终末期肝硬化患者不同，一些患者的肝功能可恢复至几乎正常。这种情况应与急性乙型肝炎相鉴别，且必须排除其他急性肝炎的病因。传统的预后系统可能不适用于慢性乙型肝炎的重度急性加重。一般来说，无论血清丙氨酸氨基转移酶水平如何，血小板减少、高胆红素血症和凝血功能障碍的患者死亡率更高。没有证据表明拉米夫定治疗可降低重度急性加重的短期死亡率。然而，与其他慢性乙型肝炎患者相比，重度急性加重患者接受拉米夫定长期治疗后，病毒学应答维持率更高、乙肝e抗原血清学转换率更高且耐药率更低。停药后病毒学复发和重度肝炎再激活很常见，因此建议进行长期抗病毒治疗。对于因重度急性加重继发肝衰竭的患者，应考虑肝移植，尤其是活体供肝肝移植。
