Fabrizi Fabrizio, Messa Piergiorgio, Dixit Vivek, Martin Paul
Division of Nephrology, Maggiore Hospital, IRCCS Foundation, Milan, Italy.
Int J Artif Organs. 2010 Jun;33(6):329-38.
Hepatitis B virus (HBV) infection persists among patients undergoing maintenance dialysis in the industrialized world. Knowledge of the epidemiology and the natural history of HBV infection in dialysis patients has markedly improved but antiviral therapy for hepatitis B remains a significant challenge in this population. A variety of therapeutic options are now available for the treatment of chronic hepatitis B, including potent new nucleos(t)ide analogues, along with standard and pegylated interferon. The most extensive experience in the dialysis population has been with lamivudine. Although several questions about lamivudine use in dialysis patients remain unanswered, it has shown potent antiviral activity: the range of clearance of HBV viremia (HBV DNA) from serum is between 56% and 100% in dialysis patients with chronic hepatitis B. Its major limitation is emergence of resistance. Tolerance to conventional or pegylated interferon monotherapy is poor in the dialysis population. There is limited data regarding adefovir dipivoxil (ADV) therapy in the dialysis population, while very little information is available about the use of the newer agents, tenofovir and entecavir, in patients with renal failure. It is recommended that dialysis patients with persistent HBsAg seropositive status be evaluated for antiviral treatment and that the decision to treat be based on the potential benefits and risks of therapy including life expectancy, candidacy for kidney transplantation, and comorbidities. Hepatitis B is relatively uncommon among patients undergoing dialysis in developed countries and this clearly hampers prospective clinical trials aimed to evaluate the efficacy and safety of therapy with nucleos(t)ide analogues for chronic hepatitis B in this population.
在工业化国家，接受维持性透析的患者中持续存在乙型肝炎病毒（HBV）感染。透析患者中HBV感染的流行病学和自然史方面的知识有了显著提高，但乙型肝炎的抗病毒治疗在这一人群中仍然是一项重大挑战。目前有多种治疗选择可用于慢性乙型肝炎的治疗，包括强效的新型核苷（酸）类似物，以及标准干扰素和聚乙二醇化干扰素。在透析人群中使用拉米夫定的经验最为丰富。尽管关于拉米夫定在透析患者中的使用仍有几个问题未得到解答，但它已显示出强效的抗病毒活性：慢性乙型肝炎透析患者血清中HBV病毒血症（HBV DNA）的清除率在56%至100%之间。其主要局限性是出现耐药性。透析人群对传统或聚乙二醇化干扰素单药治疗的耐受性较差。关于阿德福韦酯（ADV）治疗透析人群的数据有限，而关于新型药物替诺福韦和恩替卡韦在肾衰竭患者中的使用信息则非常少。建议对持续HBsAg血清学阳性的透析患者进行抗病毒治疗评估，治疗决策应基于治疗的潜在益处和风险，包括预期寿命、肾移植候选资格和合并症。在发达国家，乙型肝炎在透析患者中相对不常见，这显然阻碍了旨在评估核苷（酸）类似物治疗慢性乙型肝炎在该人群中的疗效和安全性的前瞻性临床试验。
