B型肝炎病毒感染的腎臟表現

Renal Manifestations of Hepatitis B Virus Infection

王彩融(Tsai-Jung Wang) ； 許惠恒(Wayne H-H, Sheu) ； 楊勝舜(Sheng-Shun Yang) ； 徐國雄(Kuo-Hsiung Shu)

《內科學誌》 23卷3期 (2012/06) Pp. 183-191

https://doi.org/10.6314/JIMT.2012.23(3).05

摘要

B型肝炎病毒（hepatitis B virus, HBV）感染除了影響肝臟，亦與多種腎絲球腎炎相關，包括膜狀腎絲球腎炎（membranous glomerulonephritis, MGN）、膜狀增生性腎絲球腎炎（membranoproliferative glomerulonephritis, MPGN）、A型免疫球蛋白腎絲球腎炎（immunoglobulin A nephropathy, IgAN）及局部性腎絲球硬化症（focal segmental glomerulosclerosis, FSGS）等。B型肝炎相關之腎病變亦為台灣地區最常見的次發性腎絲球腎炎。部分此些病人可溯及過去有急性肝炎發作病史，但多數病人無明顯肝臟症狀表現。血清檢驗B型肝炎表面抗原（HBsAg）及核心抗體（anti-HBc）呈陽性，而膜狀腎絲球腎炎患者的套膜抗原（HBeAg）多呈陽性。最常見的臨床症狀為腎病症候群，男性患者佔大多數。HBV抗原自發性陰轉時（特別是HBeAg），常會伴隨著蛋白尿的緩解。許多研究發現B型肝炎病毒相關的免疫複合體沈積於腎臟，學者普遍認為抗原抗體的反應為此病的中心機轉。至少四分之一的病人會進展至尿毒症，B型肝炎相關之腎絲球腎炎治療一直存有爭議，對內科醫師是一大挑戰。但越來越多研究顯示抗病毒藥物為治療此類腎臟疾病之主要選擇，包括干擾素（interferon）及干安能（lamivudine）等。2010年及2011年陸續發表的整合性研究發現此些抗病毒藥物可降低病人的蛋白尿及促進HBeAg陰轉，但類固醇則未證實有療效。B型肝炎病毒相關之腎病變的肝臟及腎臟併發症仍為臨床重要議題，未來有賴更多基礎與跨科甚至跨院臨床研究投入。

關鍵字

B型肝炎病毒 ； 腎絲球腎炎 ； 膜狀腎絲球腎炎 ； 干擾素 ； 干安能

並列摘要

Hepatitis B virus (HBV) infection can be directly associated with glomerulonephritis, such as membranous glomerulonephritis (MGN), membranoproliferative glomerulonephritis (MPGN), immunoglobulin A nephropathy (IgAN), and focal segmental glomerulosclerosis (FSGS). HBV-associated glomerular nephritis (HBV-GN) is the most common secondary glomerulonephritis in Taiwan. Some affected patients have a history of active hepatitis, but many remained asymptomatic. These patients are generally positive for hepatitis B surface antigen (HBsAg) and hepatitis B core antibody (anti-HBc), and, positive for hepatitis B envelope antigen (HBeAg) in patients with MGN. It leads to the development of nephrotic syndrome with a strong male predominance. Spontaneous clearance of HBV antigens (particularly the HBeAg) leads to abrogation of proteinuria. The isolation of immune complexes in the kidney suggests that the pathogenesis of the disease may have an immune-complex basis. At least one-quarter of the adult affected patients developed end stage renal disease, which remains to be a great challenge to internists. Current studies showed that the treatment option for HBV-associated glomerulonephritis is mainly based on immunomodulator or direct antiviral agents. Two meta-analysis review articles were published in 2010 and 2011, both articles disclosed antiviral instead of corticosteroid treatment is effective in decreasing proteinuria and achieving HBeAg seroclearance in some HBV-GN patients. There is considerable morbidity and a small but significant mortality associated with HBV-GN. In-depth basic medical studies and further well-designed multi-centered clinical trials on this disease are required in the future.

並列關鍵字

Hepatitis B virus ； Glomerulonephritis ； Membranous glomerulonephritis ； Interferon ； Lamivudine