Division of Nephrology, Department of Internal Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan.
Clin Exp Nephrol. 2011 Apr;15(2):289-93. doi: 10.1007/s10157-010-0391-z. Epub 2010 Dec 18.
Although the clinical benefits of antiviral treatment in the management of membranous nephropathy (MN) in patients with chronic hepatitis B virus (HBV) infection have been suggested, it should be evaluated more carefully. In this report, we present two cases with quiescent HBV who were administered lamivudine for either the initial treatment of MN or to control the reactivation of HBV during treatment with corticosteroids. No clinical benefit of lamivudine as an initial treatment was observed in one patient, which obliged us to commence administration of prednisolone (PSL). On the other hand, lamivudine seemed to play a pivotal role in the remission of an acute exacerbation of hepatitis B during treatment with PSL and mizoribine in the other patient. These two patients seemed to tolerate administration of PSL with or without an immunosuppressive agent well, since gradual and prompt improvements of nephrotic status were confirmed within a few months, thus suggesting the potential benefit of steroid treatment. There is little consensus regarding the optimal choice of steroids and immunosuppressants for the treatment of MN with chronic HBV infection, due to the potential for stimulation of viral replication and precipitation of hepatic flares. Our observations, however, suggest that treatment with PSL still should be reserved for quiescent HBV carriers with MN. Further studies will be required to determine the optimal timing and appropriate duration of antiviral treatment in such patients requiring long-term immunosuppression.
虽然有研究提示抗病毒治疗在慢性乙型肝炎病毒（HBV）感染患者膜性肾病（MN）治疗中的临床获益，但仍需更仔细地评估。本报告介绍了两例 HBV 处于静止期的患者，他们接受拉米夫定治疗，或在接受皮质类固醇治疗期间用于控制 HBV 再激活。在其中 1 例患者中，拉米夫定作为初始治疗未能带来临床获益，我们不得不开始使用泼尼松龙（PSL）。另一方面，在另 1 例患者中，拉米夫定似乎在 PSL 和咪喹莫特治疗期间乙型肝炎急性加重的缓解中发挥了关键作用。这两例患者似乎能够耐受 PSL 加或不加免疫抑制剂治疗，因为在几个月内确认了肾病状态的逐渐和迅速改善，从而提示激素治疗可能有益。由于病毒复制的潜在刺激和肝发作的潜在风险，对于慢性 HBV 感染合并 MN 的患者，皮质类固醇和免疫抑制剂的最佳选择尚未达成共识。然而，我们的观察结果表明，对于 HBV 处于静止期的 MN 患者，仍应保留 PSL 治疗。需要进一步研究来确定此类需要长期免疫抑制的患者中抗病毒治疗的最佳时机和适当持续时间。
