病毒性肝炎合并脂肪肝的治療策略優(yōu)質(zhì)推薦課件

1、目 錄病毒性肝炎合并脂肪肝的流行病學(xué)慢性乙型肝炎合并脂肪肝的危害和治療策略慢性丙型肝炎合并脂肪肝的危害和治療策略目 錄病毒性肝炎合并脂肪肝的流行病學(xué)全球和中國(guó)肝病的病因分布Wang FS, et al. Hepatology. 2014 ;60(6):2099-108HBV感染和脂肪肝是我國(guó)最主要的肝病病因。全球和中國(guó)肝病的病因分布Wang FS, et al. He14%-71%的慢乙肝患者合并脂肪肝Raluca Pais, et al. Clin Liver Dis 18 (2014) 165178歐洲和中東地區(qū)亞太地區(qū)14%-71%的慢乙肝患者合并脂肪肝Raluca Pais,40-86

2、%的慢性丙型肝炎患者合并脂肪肝T Asselah, et al. Gut 2006;55:12313040-86%的慢性丙型肝炎患者合并脂肪肝T Asselah,中國(guó)慢性乙型肝炎和慢性丙型肝炎患者脂肪肝的流行情況Raluca Pais, et al. Clin Liver Dis 18 (2014) 165178中國(guó)慢性乙型肝炎和慢性丙型肝炎患者脂肪肝的流行情況Ralu合并脂肪肝對(duì)慢性病毒性肝炎患者臨床預(yù)后的影響肝硬化風(fēng)險(xiǎn)肝細(xì)胞癌風(fēng)險(xiǎn)范建高. 中華肝臟病雜志; 2009;17(11):801-805合并脂肪肝對(duì)慢性病毒性肝炎患者臨床預(yù)后的影響肝硬化肝細(xì)胞癌問 題如何正確理解病毒肝與脂肪肝之間的

3、關(guān)系？如何治療病毒肝合并脂肪肝的患者？病毒性肝炎（乙型、丙型） 脂肪肝 ？病毒性肝炎（乙型、丙型） + 脂肪肝 ？以治療脂肪肝為主？以治療病毒肝為主？雙管齊下？問 題如何正確理解病毒肝與脂肪肝之間的關(guān)系？病毒性肝炎（乙目 錄病毒性肝炎合并脂肪肝的流行病學(xué)慢性乙型肝炎合并脂肪肝的危害和治療策略慢性丙型肝炎合并脂肪肝的危害和治療策略目 錄病毒性肝炎合并脂肪肝的流行病學(xué)肝臟在肥胖相關(guān)并發(fā)癥發(fā)病機(jī)制中的關(guān)鍵角色Thomas Karlas, et al. Best Practice & Research Clinical Endocrinology & Metabolism 2013; 27:19520

4、8肝臟在肥胖相關(guān)并發(fā)癥發(fā)病機(jī)制中的關(guān)鍵角色Thomas KaHBV 感染與代謝綜合征：事實(shí)還是虛構(gòu)？Chia-Chi Wang, et al. J Gastroenterol Hepatol. 2014 Aug 5. doi: 10.1111/jgh.12700. Epub ahead of printHBV 感染與代謝綜合征：事實(shí)還是虛構(gòu)？Chia-Chi WHBV感染與代謝綜合征的相互關(guān)系：臨床研究匯總研究設(shè)計(jì)樣本量結(jié)果Jarcuska PCross-section855A higher viral load in patient of chronic HBV infection with

5、 metabolic syndrome than those without.Chung THCross-section9474HBV infection was negatively associatedwith metabolic syndrome in men.Jinjuvadia RLarge population databaseChronicHBV: pastexposure toHBV=593594:7280620Chronic HBV infection was inversely associatedwith metabolic syndromeLi WC2013Case s

6、eries26305The prevalence of metabolic syndromewas not different between HBV and non-HBV patientsLi X2012Case series138Metabolic syndrome in HBV patientscorrelated with insulin resistance and less effect of virusWong VW2012Case series1013HBV infection is associated with lower prevalence of metabolic

7、syndrome than controls (11% vs. 20.2%; p=0.034)Jan CF 2006Population basedCross-sectional study53528There was an inverse association betweenmetabolic syndrome and HBV infection.Chia-Chi Wang, et al. J Gastroenterol Hepatol. 2014 Aug 5. doi: 10.1111/jgh.12700. Epub ahead of printHBV感染與代謝綜合征的相互關(guān)系：臨床研究

8、匯總研究設(shè)計(jì)樣本慢性HBV感染與代謝綜合征相關(guān)性的薈萃分析Chia-Chi Wang, et al. J Gastroenterol Hepatol. 2014 Aug 5. doi: 10.1111/jgh.12700. Epub ahead of printOR= 0.82慢性HBV感染與代謝綜合征相關(guān)性的薈萃分析Chia-Chi 合并代謝綜合征(包括脂肪肝)對(duì)HBV肝病進(jìn)展的影響肝纖維化肝硬化研究者主要結(jié)論來源Mena , et al. 慢性非活動(dòng)性HBV攜帶者，代謝綜合征與纖維化發(fā)展有關(guān)J Gastroenterol Hepatol. 2014 Jan;29(1):173-8.Wong

9、 GL, et al. 慢性乙肝患者合并代謝綜合征增加肝纖維化進(jìn)展風(fēng)險(xiǎn)Aliment Pharmacol Ther. 2014 Apr;39(8):883-93.Wong GL, et al. 慢性乙肝患者，代謝綜合征增加肝硬化風(fēng)險(xiǎn)Gut. 2009;58(1):111-7.Huang YW, et al. 慢性乙肝合并新發(fā)糖尿病的患者，肝硬化和失代償風(fēng)險(xiǎn)增加Clin Infect Dis. 2013. Epub ahead of print.Lin YC, et al. HBV攜帶者合并超聲下脂肪肝：對(duì)臺(tái)灣成年人的肝損傷有協(xié)同作用World J Gastroenterol. 2007;13(

10、12):1805-10.風(fēng)險(xiǎn)合并代謝綜合征(包括脂肪肝)對(duì)HBV肝病進(jìn)展的影響肝纖維化HBV攜帶者合并超聲下脂肪肝對(duì)肝臟損傷具有協(xié)同作用Yu-Cheng Lin, et al. World J Gastroenterol 2007 ; 13(12): 1805-1810A cross-sectional retrospective analysis of health records including medical history, physical examination, abdominal sonogram, blood biochemistry and hepatic virolo

11、gical tests. We utilized the Students t-test, chi-square, multivariate logistic regression and synergy index to assess risks for LD.HBV攜帶者合并超聲下脂肪肝對(duì)肝臟損傷具有協(xié)同作用Yu-合并NAFLD的CHB患者肝酶和肝組織學(xué)分期比不合并NAFLD的CHB升高Arezoo Estakhri, et al. Open Journal of Gastroenterology, 2012, 2:18-21 retrospectively evaluated 94 “e

12、Ag” negative CHB patients (with NAFLD: 44, without NAFLD: 50). In the NAFLD group, increase in AST, ALT, stage (P = 0.002), grade, and total score of liver biopsy were independently related to non-alcoholic fatty liver disease, while HBV-DNA viral load did not correlate with the presence of a fatty

13、liver. 合并NAFLD的CHB患者肝酶和肝組織學(xué)分期比不合并NAFL慢性病毒性肝炎合并脂肪肝的治療策略整體治療的前提：脂肪肝的基礎(chǔ)治療最根本的治療：抗病毒治療重要組成部分：保肝藥物改變生活方式治療原發(fā)病和去除相關(guān)危險(xiǎn)因素：肥胖、2型糖尿病抗病毒藥物保肝藥物一般可選用多烯磷酯酰膽堿、水飛薊素等1-2種，治療半年至1年以上。施軍平, 等. 實(shí)用肝臟病雜志, 2008; 11(4):278-280慢性病毒性肝炎合并脂肪肝的治療策略整體治療的前提：最根本的治獲得持久病毒學(xué)應(yīng)答的CHC患者的HCC累積發(fā)生率C 70/59（129）In the NAFLD group, increase in AS

14、T, ALT, stage (P = 0.慢性丙型肝炎合并脂肪肝的危害和治療策略0002 between grade 2 and grade 1 or grade 0).ALT降低50%有效病毒性肝炎合并脂肪肝的流行病學(xué)HBV感染合并NAFLD對(duì)肝細(xì)胞損傷有協(xié)同作用，患者肝酶和肝組織學(xué)分期比不合并NAFLD的CHB高；L Castera, et al.Immunohistochemical staining for HCV core antigen in the infected Huh 7.40-86%的慢性丙型肝炎患者合并脂肪肝C 70/59（129）The prevalence of m

15、etabolic syndromeWong GL, et al.Thomas Karlas, et al.J Gastroenterol Hepatol.Antiviral Research 2014;105: 92995 mg/kg body weight/weekly and ribavirin 10001200 mg/daily) for at least three months for non-responders (same virological load before and after) and for 12 months if responders or partial r

16、esponders (decrease in HCV-RNA 2 log 10)Both groups were closely matched by the main clinical variables associated with insulin resistance and the degree of liver fibrosis.Intracytoplasmic fat accumulation in these cells was visualized by Nile red staining and electron microscopy then quantified by

17、microfluorometry.改變生活方式通過健康宣教以及心理和行為修正治療，做到“合理膳食、增加運(yùn)動(dòng)、節(jié)制飲酒、慎用肝毒藥物以及避免接觸肝毒物質(zhì)”。施軍平, 等. 實(shí)用肝臟病雜志, 2008; 11(4):278-280獲得持久病毒學(xué)應(yīng)答的CHC患者的HCC累積發(fā)生率改變生活方式抗炎保肝類藥物治療病毒性肝炎合并脂肪肝應(yīng)用IFN-類抗病毒治療時(shí)，ALT10ULN，TBIL50mol/L的患者；或使用過程中ALT或AST繼續(xù)上升10ULN應(yīng)用NUCs過程中少數(shù)ALT持久波動(dòng)或ALT復(fù)升（除外耐藥因素）者（必要時(shí)尋找其他病因，相應(yīng)處置）使用抗病毒藥物正規(guī)治療中，ALT、AST仍異常者（必要時(shí)尋

18、找其他病因，相應(yīng)處置）ALT、AST異常，但暫不宜應(yīng)用IFN-及NUCs治療的CHB、CHC、肝硬化代償或失代償患者。中華醫(yī)學(xué)會(huì)感染病學(xué)分會(huì)，肝臟炎癥及其防治專家共識(shí)專家委員會(huì). 中國(guó)實(shí)用內(nèi)科雜志, 2014;34(2): 152-162針對(duì)病毒感染合并脂肪肝的患者，是否適用？抗炎保肝類藥物治療病毒性肝炎合并脂肪肝應(yīng)用IFN-類抗病毒抗炎保肝藥物顯著改善乙肝合并脂肪肝患者的肝生化指標(biāo)選擇病毒性肝炎合并脂肪肝136例，慢性乙肝112例，慢性丙肝22例，急性乙肝2例對(duì)照組:一般治療+肝炎治療；治療組:一般治療+肝炎治療+多烯磷脂酰膽堿膠囊 2片/次 3次/日；療 程:3個(gè)月姜寧華.易善復(fù)治療病毒性

19、肝炎合并脂肪肝臨床療效評(píng)估. 中國(guó)現(xiàn)代應(yīng)用藥學(xué).2004;21(3):235-7抗炎保肝藥物顯著改善乙肝合并脂肪肝患者的肝生化指標(biāo)選擇病毒抗炎保肝藥物治療顯著改善乙肝合并脂肪肝患者的影像學(xué)選擇病毒性肝炎合并脂肪肝136例，慢性乙肝112例，慢性丙肝22例，急性乙肝2例對(duì)照組:一般治療+肝炎治療；治療組:一般治療+肝炎治療+多烯磷脂酰膽堿膠囊 2片/次 3次/日；療 程:3個(gè)月組間比較，p50%有效針對(duì)病毒感染合并脂肪肝的患者，是否適用？J Gastroenterol Hepatol.Clin Liver Dis 18 (2014) 165178避免使用減肥和調(diào)脂藥物誘發(fā)的肝膽損傷Wong GL

20、, et al.他汀類藥物：用于CHC合并脂肪肝的治療需要更大型、前瞻性、隨機(jī)研究數(shù)據(jù)評(píng)估。8 g/天)或 3x 2 膠囊，安慰劑每日使用24周，有效者（ALT 下降 50）繼續(xù)治療24周，176 病人完成試驗(yàn): Hep.World J Gastroenterol.metabolic syndrome and HBV infection.Feyza Gunduz, et al.慢性乙型肝炎合并脂肪肝的危害和治療策略中國(guó)實(shí)用內(nèi)科雜志, 2014;34(2): 152-162胰島素增敏劑：改善胰島素抵抗；2014 Aug 5.基礎(chǔ)治療: a-干擾素Hep.多項(xiàng)研究提示改變生活方式有效改善脂肪肝Ar

21、ezoo Estakhri, et al.FFA促進(jìn)HCV在肝細(xì)胞復(fù)制Immunohistochemical staining for HCV core antigen in the infected Huh 7.5 cells in the presence of different concentrations of FAA after 15 daysHCV infected Huh-7.5 cells were cultured with a mixture of saturated (palmitate) and unsaturated (oleate) long-chain free

22、 fatty acids (FFA). Intracytoplasmic fat accumulation in these cells was visualized by Nile red staining and electron microscopy then quantified by microfluorometry. The effect of FFA treatment on HCV replication and IFN- antiviral response was measured by flow cytometric analysis, Renilla luciferas

23、e activity, and real-time RT-PCRFeyza Gunduz, et al. Virology Journal 2012, 9:143選擇病毒性肝炎合并脂肪肝136例，慢性乙肝112例，慢性丙肝游離脂肪酸降低IFN對(duì)HCV的治療作用HCV infected Huh-7.5 cells were cultured with a mixture of saturated (palmitate) and unsaturated (oleate) long-chain free fatty acids (FFA). Intracytoplasmic fat accumula

24、tion in these cells was visualized by Nile red staining and electron microscopy then quantified by microfluorometry. The effect of FFA treatment on HCV replication and IFN- antiviral response was measured by flow cytometric analysis, Renilla luciferase activity, and real-time RT-PCRFeyza Gunduz, et

25、al. Virology Journal 2012, 9:143游離脂肪酸降低IFN對(duì)HCV的治療作用HCV infecteIR降低抗病毒治療病毒學(xué)應(yīng)答率：EVRHOMA：穩(wěn)態(tài)模式評(píng)估法，Homeostasis Model Assessment，用于評(píng)估胰島素抵抗。J . J . BLONSKY & S. A. HARRISON. Aliment Pharmacol Ther 27, 855865To conduct a systematic, evidence-based review of the epidemiology, pathophysiology and potential tr

26、eatments of coexistent NAFLD and CHC. The terms such as hepatitis C, fatty liver, NAFLD, nonalcoholic steatohepatitis and steatosis were searched on PubMed up to January 2008. References from selected articles and pertinent abstracts were also included.IR降低抗病毒治療病毒學(xué)應(yīng)答率：EVRHOMA：穩(wěn)態(tài)模式評(píng)估IR降低抗病毒治療病毒學(xué)應(yīng)答率：S

27、VRHOMA：穩(wěn)態(tài)模式評(píng)估法，Homeostasis Model Assessment，用于評(píng)估胰島素抵抗。J . J . BLONSKY & S. A. HARRISON. Aliment Pharmacol Ther 27, 855865To conduct a systematic, evidence-based review of the epidemiology, pathophysiology and potential treatments of coexistent NAFLD and CHC. The terms such as hepatitis C, fatty live

28、r, NAFLD, nonalcoholic steatohepatitis and steatosis were searched on PubMed up to January 2008. References from selected articles and pertinent abstracts were also included.IR降低抗病毒治療病毒學(xué)應(yīng)答率：SVRHOMA：穩(wěn)態(tài)模式評(píng)估脂肪肝分級(jí)不同，肝細(xì)胞癌累積發(fā)生率差異顯著P = 0.0002 between grade 2 and grade 1 or grade 0).Atsushi Tanaka, et al. W

29、orld J Gastroenterol 2007 October 21; 13(39): 5180-5187獲得持久病毒學(xué)應(yīng)答的CHC患者的HCC累積發(fā)生率Grade 2，Grade 1，Grade 0 指肝脂肪變分級(jí)脂肪肝分級(jí)不同，肝細(xì)胞癌累積發(fā)生率差異顯著P = 0.00小結(jié)：與NAFLD的相互關(guān)系NAFLDHCV胰島素抵抗相關(guān)IR影響抗病毒療效脂肪肝分級(jí)與CHC患者肝細(xì)胞癌風(fēng)險(xiǎn)相關(guān)小結(jié)：與NAFLD的相互關(guān)系NAFLDHCV胰島素抵抗相關(guān)脂慢性病毒性肝炎合并脂肪肝的治療現(xiàn)狀改變生活方式，包括運(yùn)動(dòng)和減重：但在HCV合并脂肪肝人群中尚缺乏正規(guī)的臨床研究數(shù)據(jù)。1抗病毒治療。2抗炎保肝類藥物：

30、保護(hù)肝細(xì)胞、拮抗氧應(yīng)激脂質(zhì)過氧化、抗炎、抗凋亡、抗纖維化，還避免使用減肥和調(diào)脂藥物誘發(fā)的肝膽損傷。2胰島素增敏劑：改善胰島素抵抗；提高持久病毒學(xué)應(yīng)答率？需要進(jìn)一步臨床研究的證明。1他汀類藥物：用于CHC合并脂肪肝的治療需要更大型、前瞻性、隨機(jī)研究數(shù)據(jù)評(píng)估。1Anish Patel, and Stephen A. Harrison. Gastroenterology & Hepatology, 2012;8(5):305-312施軍平, 等. 實(shí)用肝臟病雜志, 2008; 11(4):278-280慢性病毒性肝炎合并脂肪肝的治療現(xiàn)狀改變生活方式，包括運(yùn)動(dòng)和減多項(xiàng)研究提示改變生活方式有效改善脂肪肝

31、Valerio Nobili, et al. BMC Medicine 2011, 9:70多項(xiàng)研究提示改變生活方式有效改善脂肪肝Valerio No通過生活方式干預(yù)代謝綜合征對(duì)抗病毒療效的影響Tarantino G, et al. Gut. 2006;55:585病毒學(xué)應(yīng)答率，HCV-RNA 2 log 10n=17n=15All patients were offered standard combined antiviral therapy Peg-interferon alpha 2b 1.5 mg/kg body weight/weekly and ribavirin 1000120

32、0 mg/daily) for at least three months for non-responders (same virological load before and after) and for 12 months if responders or partial responders (decrease in HCV-RNA 2 log 10)P=0.035 X2通過生活方式干預(yù)代謝綜合征對(duì)抗病毒療效的影響Taranti有效的抗病毒治療顯著改善基因3型丙肝患者脂肪肝情況L Castera, et al. Gut 2004;53:420424A total of 151 pat

33、ients (37 with HCV genotype 3; 114 with HCV non-3 genotypes) were selected to study the relationship between steatosis evolution and HCV clearance after antiviral treatment in patients with chronic hepatitis C and paired liver biopsiesImprovement was defined as a decrease of at least one grade betwe

34、en the two biopsies; stability was defined as identical grades between the two biopsies; worsening of steatosis was defined as an increase of at least one grade between the two biopsies有效的抗病毒治療顯著改善基因3型丙肝患者脂肪肝情況L CaFFA促進(jìn)HCV在肝細(xì)胞復(fù)制FFA促進(jìn)HCV在肝細(xì)胞復(fù)制Epub ahead of print.The effect of FFA treatment on HCV rep

35、lication and IFN- antiviral response was measured by flow cytometric analysis, Renilla luciferase activity, and real-time RT-PCRL Castera, et al.Feyza Gunduz, et al.Wong GL, et al.Thomas Karlas, et al.ALT、AST異常，但暫不宜應(yīng)用IFN-及NUCs治療的CHB、CHC、肝硬化代償或失代償患者。中華醫(yī)學(xué)會(huì)感染病學(xué)分會(huì)，肝臟炎癥及其防治專家共識(shí)專家委員會(huì).抗病毒藥物治療根本脂肪肝分級(jí)不同，肝細(xì)胞癌

36、累積發(fā)生率差異顯著International Journal of Infectious Diseases 2012;16 :e436e4418 g/天)或 3x 2 膠囊，安慰劑每日使用24周，有效者（ALT 下降 50）繼續(xù)治療24周，176 病人完成試驗(yàn): Hep.抗病毒治療后與脂肪肝改善相關(guān)的獨(dú)立影響因素Metabolic syndrome in HBV patientsImprovement was defined as a decrease of at least one grade between the two biopsies;World J Gastroenterol 20

37、07 October 21; 13(39): 5180-5187合并脂肪肝對(duì)慢性病毒性肝炎患者臨床預(yù)后的影響HBV感染與代謝綜合征的相互關(guān)系：臨床研究匯總抗病毒治療后與脂肪肝改善相關(guān)的獨(dú)立影響因素L Castera, et al. Gut 2004;53:420424A total of 151 patients (37 with HCV genotype 3; 114 with HCV non-3 genotypes) were selected to study the relationship between steatosis evolution and HCV clearance a

38、fter antiviral treatment in patients with chronic hepatitis C and paired liver biopsiesFFA促進(jìn)HCV在肝細(xì)胞復(fù)制抗病毒治療后與脂肪肝改善相關(guān)的服用胰島素增敏劑二甲雙胍有效改善基因1型丙肝患者胰島素抵抗Peg 干擾素-+利巴韋林+二甲雙胍Peg 干擾素-+利巴韋林Jian-Wu Yu, et al. International Journal of Infectious Diseases 2012;16 :e436e441P50%有效P=0.016治療24周時(shí)，慢性丙肝患者的生化（ALT）應(yīng)答率ALT降低5

39、0%的病人比例試驗(yàn)發(fā)現(xiàn)， IFN+PPC組比 IFN+安慰劑組可實(shí)現(xiàn)更好的ALT治療反應(yīng)率。在 24周時(shí)，ALT降低50%的病人比例IFN+PPC組顯著多于IFN+安慰劑組。表明，多烯磷脂酰膽堿膠囊可以改善病毒性肝炎患者的肝功能水平，有效治療病毒性肝炎?；A(chǔ)治療: a-干擾素Hep.B: 5 mio I.U. s.c. 3x 每周，24周，Hep.C: 3 mio I.U. s.c. 3x 每周，24周。試驗(yàn)藥物:3 x 2 膠囊， PPC 每日使用 (1.8 g/天)或 3x 2 膠囊，安慰劑每日使用24周，有效者（ALT 下降 50）繼續(xù)治療24周，176 病人完成試驗(yàn): Hep.B. 2

40、2/25（47）， Hep.C 70/59（129）多烯磷脂酰膽堿聯(lián)合干擾素有效提高慢性丙肝患者生化應(yīng)答率(2多烯磷脂酰膽堿聯(lián)合干擾素48周時(shí)慢性丙肝患者ALT復(fù)常率Niederau C et al: Hepato Gastroenterology 1998;45:797-804P=0.06治療24周時(shí)ALT降低50的病人，停用IFN，繼續(xù)使用PPC（每日3次，每次2粒）或安慰劑治療，第48周時(shí)的ALT復(fù)常率ALT正常的病人比例基礎(chǔ)治療: a-干擾素Hep.B: 5 mio I.U. s.c. 3x 每周，24周，Hep.C: 3 mio I.U. s.c. 3x 每周，24周。試驗(yàn)藥物:3

41、x 2 膠囊， PPC 每日使用 (1.8 g/天)或 3x 2 膠囊，安慰劑每日使用24周，有效者（ALT 下降 50）繼續(xù)治療24周，176 病人完成試驗(yàn): Hep.B. 22/25（47）， Hep.C 70/59（129）多烯磷脂酰膽堿聯(lián)合干擾素48周時(shí)慢性丙肝患者ALT復(fù)常率N基礎(chǔ)治療: a-干擾素Hep.0002 between grade 2 and grade 1 or grade 0).小結(jié)：丙肝合并脂肪肝的危害和治療策略通過生活方式干預(yù)代謝綜合征對(duì)抗病毒療效的影響實(shí)用肝臟病雜志, 2008; 11(4):278-280Gut 2004;53:4204240002 betwe

42、en grade 2 and grade 1 or grade 0).J Gastroenterol Hepatol.合并脂肪肝對(duì)慢性病毒性肝炎患者臨床預(yù)后的影響治療原發(fā)病和去除相關(guān)危險(xiǎn)因素：肥胖、2型糖尿病游離脂肪酸降低IFN對(duì)HCV的治療作用2004;21(3):235-7易善復(fù)治療病毒性肝炎合并脂肪肝臨床療效評(píng)估.International Journal of Infectious Diseases 2012;16 :e436e441Cross-section針對(duì)病毒感染合并脂肪肝的患者，是否適用？慢性病毒性肝炎合并脂肪肝的治療現(xiàn)狀如何正確理解病毒肝與脂肪肝之間的關(guān)系？中國(guó)實(shí)用內(nèi)科雜志

43、, 2014; 34(2):152-162J Gastroenterol Hepatol.小結(jié)：丙肝合并脂肪肝的危害和治療策略HCV與脂肪肝在發(fā)病機(jī)理上相互促進(jìn)；NAFLD合并HCV和IR降低抗病毒治療的病毒學(xué)應(yīng)答率；治療策略包括針對(duì)脂肪肝的基礎(chǔ)治療、抗病毒治療和保肝治療等；胰島素增敏劑和他汀類對(duì)抗病毒治療效果的影響尚需進(jìn)一步的研究；抗炎保肝藥物如多烯磷脂酰膽堿，聯(lián)合干擾素能提高干擾素治療丙肝的療效?；A(chǔ)治療: a-干擾素Hep.小結(jié)：丙肝合并脂肪肝的危害和總 結(jié)病毒性肝炎合并脂肪肝非常常見。病毒性肝炎合并脂肪肝增加肝硬化和肝細(xì)胞癌風(fēng)險(xiǎn)。慢性病毒性肝炎合并脂肪肝的治療策略包括：針對(duì)脂肪肝的基礎(chǔ)

44、治療前提抗病毒藥物治療根本保肝藥物治療重要組成部分總 結(jié)病毒性肝炎合并脂肪肝非常常見。謝 謝 聆 聽 ！謝 謝 聆 聽 ！合并脂肪肝對(duì)慢性病毒性肝炎患者臨床預(yù)后的影響肝硬化風(fēng)險(xiǎn)肝細(xì)胞癌風(fēng)險(xiǎn)范建高. 中華肝臟病雜志; 2009;17(11):801-805合并脂肪肝對(duì)慢性病毒性肝炎患者臨床預(yù)后的影響肝硬化肝細(xì)胞癌問 題如何正確理解病毒肝與脂肪肝之間的關(guān)系？如何治療病毒肝合并脂肪肝的患者？病毒性肝炎（乙型、丙型） 脂肪肝 ？病毒性肝炎（乙型、丙型） + 脂肪肝 ？以治療脂肪肝為主？以治療病毒肝為主？雙管齊下？問 題如何正確理解病毒肝與脂肪肝之間的關(guān)系？病毒性肝炎（乙肝臟在肥胖相關(guān)并發(fā)癥發(fā)病機(jī)制中的

45、關(guān)鍵角色Thomas Karlas, et al. Best Practice & Research Clinical Endocrinology & Metabolism 2013; 27:195208肝臟在肥胖相關(guān)并發(fā)癥發(fā)病機(jī)制中的關(guān)鍵角色Thomas Ka合并NAFLD的CHB患者肝酶和肝組織學(xué)分期比不合并NAFLD的CHB升高Arezoo Estakhri, et al. Open Journal of Gastroenterology, 2012, 2:18-21 retrospectively evaluated 94 “eAg” negative CHB patients (wi

46、th NAFLD: 44, without NAFLD: 50). In the NAFLD group, increase in AST, ALT, stage (P = 0.002), grade, and total score of liver biopsy were independently related to non-alcoholic fatty liver disease, while HBV-DNA viral load did not correlate with the presence of a fatty liver. 合并NAFLD的CHB患者肝酶和肝組織學(xué)分期

47、比不合并NAFL小結(jié)：慢性乙型肝炎合并脂肪肝的治療策略合并代謝綜合征對(duì)HBV肝病進(jìn)展有影響(如可能增加肝纖維化、肝硬化風(fēng)險(xiǎn))；HBV感染合并NAFLD對(duì)肝細(xì)胞損傷有協(xié)同作用，患者肝酶和肝組織學(xué)分期比不合并NAFLD的CHB高；對(duì)于慢乙肝合并脂肪肝的患者，脂肪肝的基礎(chǔ)治療是前提，抗病毒治療是根本、保肝藥物治療是重要組成部分；抗炎保肝類藥物能有效改善乙肝合并脂肪肝的患者肝功能和影像學(xué)。小結(jié)：慢性乙型肝炎合并脂肪肝的治療策略合并代謝綜合征對(duì)HB脂肪肝分級(jí)不同，肝細(xì)胞癌累積發(fā)生率差異顯著P = 0.0002 between grade 2 and grade 1 or grade 0).Atsushi Tanaka, et al. World J Gastroenterol 2007 October 21; 13(39): 5180-5187獲得持久病毒學(xué)應(yīng)答的CHC患者的HCC累積發(fā)生率Grade 2，Grade 1，Grade 0 指肝脂肪變分級(jí)脂肪肝分級(jí)不同，肝細(xì)胞癌累積發(fā)生率差異顯著P = 0.00多項(xiàng)研究提示改變生活方式有效改善脂肪肝V