Vlachogiannakos Jiannis, Papatheodoridis George V
Department of Gastroenterology, Medical School of National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece.
Liver Int. 2016 Jan;36 Suppl 1:93-9. doi: 10.1111/liv.12996.
Immunotolerant patients with chronic hepatitis B virus (HBV) infection are characterized by positive HBeAg, high viral replication, persistently normal ALT and no or minimal liver damage. Since the risk of the progression of liver disease and the chance of a sustained response with existing anti-HBV agents are low, current guidelines do not recommend treatment but close monitoring with serial alanine aminotransferase (ALT) and HBV DNA measurements instead. However, not treating all these patients is a concern because advanced histological lesions have been reported in certain cases who are usually older (>30-40 years old), and continued high HBV replication could increase the risk of hepatocellular carcinoma (HCC). Thus, the optimal management of immunotolerant patients is often individualised according to age, which is associated with histological severity and patient outcome. In particular, immunotolerant patients <30 years old can be monitored for ALT and HBV DNA, while treatment is often recommended in the few patients over 40. A liver biopsy and/or non-invasive assessment of fibrosis may be helpful to determine the therapeutic strategy in patients between 30 and 40 years old. Moreover, there are three specific subgroups of immunotolerant patients who often require treatment with oral anti-HBV agents: patients who will receive immunosuppressive treatment or chemotherapy, women with serum HBV DNA >10(6-7) IU/ml during the last trimester of pregnancy and certain healthcare professionals with high viraemia levels. More studies are needed to further clarify the natural history for the optimal timing of treatment in this setting.
慢性乙型肝炎病毒（HBV）感染的免疫耐受患者的特征为HBeAg阳性、病毒复制活跃、谷丙转氨酶（ALT）持续正常且无或仅有轻微肝损伤。由于这些患者发生肝病进展的风险以及使用现有抗HBV药物获得持续应答的几率较低，当前指南不建议进行治疗，而是建议通过连续检测ALT和HBV DNA进行密切监测。然而，并非对所有这些患者都不进行治疗，这是因为在某些通常年龄较大（>30 - 40岁）的患者中已报告存在严重的组织学病变，并且持续的高HBV复制会增加肝细胞癌（HCC）的风险。因此，免疫耐受患者的最佳管理通常根据年龄个体化，年龄与组织学严重程度和患者预后相关。特别是，<30岁的免疫耐受患者可监测ALT和HBV DNA，而对于40岁以上的少数患者通常建议进行治疗。肝活检和/或纤维化的非侵入性评估可能有助于确定30至40岁患者的治疗策略。此外，有三个特定的免疫耐受患者亚组通常需要使用口服抗HBV药物进行治疗：将接受免疫抑制治疗或化疗的患者、妊娠晚期血清HBV DNA>10(6 - 7) IU/ml的女性以及某些病毒血症水平高的医护人员。需要更多研究来进一步阐明这种情况下治疗的最佳时机的自然史。
