Tap chi GAN MAT VIET NAM so 13-2010 69
D i e u t r i V i e m g a n B m a n t i n h M o t m a t r a n c a n n a m v u n g t r u o c k h i d i e u t r i
PHAM SONG*
Summary
Treatment of chronic hepatitis B which meets the criteria needing for treatment is considered as a maze by the reason that it needs high tech- nology for loading HBV in the plasma, for evaluation of the resistance against drug, for detecting chronic hepatitis B with HBeAg (-)by mutation of core gen or the promotor of core gen by this HBeAg is (-) but the replication of DNA -HBV continue to develop and the prog- noses of the future course is worst than chronic hepatis HBeAg (+). Now occur the occult chronic hepatis B and it means any classic markers of HBV in the serum are (-) even HBsAg . So that in this case the vims loading is the golden criteria and secondly consist the biopsy of the liver to know precisely it is the persistent chronic hepatitis or an aggressive one.
Treatment of choice by my recommenndation for naive patients is to use lonely Barucle Dieu tri Viem gan B man tinh la 1 me cung theo Anna SukFong (1). Vi sao lai nhu vay.Chon benh nhan Vie-m gan B man tinh (VGBMT)de dieu tri chi co 2 chi so vang. Mot la sinh thiet gan chimg to la dang VGBMT the tan cong ; hai la nong do HBV-DNA trong huyet mong cao >10005 copies /m3 voi ky thuat nhay nhat la PCR- RT.ctia ADN -HBV.
Me cung VGBMT con do co nhieu VGBMT HBeAg (-) vi dot bien core gen hay viing khoi xuong tao ra stop codon san xuat HBeAg. DNA -HBV van tang sinh.tien luong xau hern nhieu so vdi VGBMT HBeAg (+)vi vay tieu chi vang la so luong copies hay DNA -HBV trong huyet tuong (1).
*Tong hoi Y hoc Vict Nam
(Entacavir ) 0,5mg/once a day during 2 years by advantage about high inhibited on repro- duction of DNA-HBV,high barrier of drug resistance and no side effect beyond take care one on the heart with long time of continuing trearment. The prevention from CHB to cir- rhosis is relieable by so the percentage of occurring hepatoma will diminish but it is not sure if you coulden't know whether the inte- gration of DNA-HBV on DNA -liver cells is occured or not because 90% of hepatoma related with HBV is found there are integration and beyond this the presence of X gen. The general recommedation is before to treat CHB you have make a bilan of which tech you have to use on HBVloading,on detection of drug resistance and to know on CHB HBeAg (-) and occult CHB.In sum you shall be care before navigating in the maze of CHB.
Ngoai ra me cung con do Viem gan B man tinh tiem an nghTa la khi cac marker huyet thanh kinh dien deu (-) ke ca HBsAg va co the xuat hien HBsAb la dau hieu tuyet dinh eua dieu tri nen khong dua vao tieu chi ket qua dieu tri,hay co ca HBcAb nhung nong do HBV-DNA lai rat cao vdi ky thuat nhay nhat (2).
Nhung ky thuat thong dung dinh luong.ADN- HBV nhu ky thuat Cobas cac loai.Bayer version 3,Hybrid capture 2 ADN -HBV hay Plus da duoc cong nhan phat hien ADN-HBV khi co cac marker tang cao nhung khong phat hien duoc
<100vge/ml.( vge co nghTa la tuong duong genome virus(virus genome equivalent ) trong huyet thanh nhat la trong xet nghiem 1 lin.(3)
70 Tap chi GAN MAT VIET NAM s6 13-2010
Tuy thuoc dinh nghTa dom vi qudc te (IU) diing trong cac loai xet nghiem ma miic vge tuong duong co the 5,5 den 615IU /mL. Diing tet nhieu lan huyet thanh bach ciu,bach cau don nhan,ngoai vi,va khi co the lam tet tren to chirc te bao gan va bang khuech dai nhung vung khong chong lan khac nhau ciia genome lam tang su phat hien nhiem hepadnavirus cao hon nhieu lan vdi ky thuat phat hien hien co.
Ap dung mo hinh thuc nhiem ve HBV diing con Woodchuck vimg Dong bac My (manola monax) vdi tet Ncsted-PCR /NAH lay nucleotid lam primer dac hieu cho gen X ciia virus va trinh tu chudi gen ma hda gen vd (S);
tiep theo phan tich sim pham khuech dai bang Southern -blot. Cdng vdi ky thuat rat nhay ciia PCR/NAII lam nen cd the phat hien sinh trudng cua genome trung gian nhu cccDNA, virus mRNA dac hieu vdi mire nhay giua 10-
1 OOvge /ml ciia tdng the DNA hay ARN.
Phat hien duoc cccDNA la budc sinh trudng thir 2 trong chu ky sinh trudng cua HBV la rat quan trong de chan doan VGBMT tiem an.Nhirng ky thuat nay da irng dung trong VGBMT tiem an bang xet nghiem huyet thanh,huyet tuong,trong te bao gan,lympho bao.Cdng vice nghien ciru tiep tuc dc phat hien cue nhay bDNA -HBV virus cue thap (< 1 Ovge/ml) ciia VGBMT tiem an cdng vdi ket qua thuc nghiem tren con Woodchuck de danh gia VGBMT tiem an ma dau hieu huyet thanh hau nhu da khdi (1)
Muc dich dieu tri viem gan B man tinh can dieu tri chii yeu la ire che luong HBV-DNA tdi mire khdng phiit hien duoc va giir duoc lau dai Chuyen ddi huyet thanh ciing la mdt yeu cau nhung do cd VGBMT HBeAg (-)va VGBMT tiem an nen sd luong HBV-DNA trong huyet tuong la chuan cao nhat va thii 2 la chuyen ddi td chirc hoc tir VGBMT tan cdng thanh VGBMT ton tai..
Dieu tri bang thudc nao ?(5,6)
Cho den nay (2010)3 thir da diing duoc 10 nam
la Interferon a2b (INF 1980)va nay la Peg- INFF a 2a, Lamivudine. Adefovir va 8 thudc mdi nhung duoc danh gia cao la Barucle (Enta- cavir) so toan dien co che tac dung tren ba giai doan tir tic che primer, lie che men sao chep nguoc,irc che tdng hop DNA soi(+).
Khang thudc tren benh nhan chua dimg thudc tic HBV thi chua cd bao cao cdn tren benh nhan da khang lamivudine ket hop vdi Entacavirr thi da thay khi dieu tri keo dai 80-100 man va da phat hien nhieu dot bien dii duoc phat hien nhu rtM205V, rtT 184G, rtS2021. Tai sao ket hop lamivudine da khang vdi Entaeavir gay dot bien khang Entaeavir chua duoc sang to Dieu tri bao lau kinh nghiem ciia tdi tuy khdng nhieu la 2 nam vdi lieu 0,5mg/ngay nhung rat ket qua do ben vung sau 6 thang van tot tic che 1 IBV-DNA khdng phat hien duoc.
Dieu trj viem gan B man tinh cd ngan can tien tdi xo gan, ung thu bieu md gan nguyen phat khdng?
Dieu tri ire che HBV tdi da thi cd tai lieu ndi giam duoc sang xo gan va gian tiep giam ung thu gan nguyen phat vi 85% ung thu gan la tir xo gan nen cd ndi la giiim tan xuat sinh ung thu gan nhung khdng ndi ty le cu the. Do can biet la cd tich hop DNA-HBV vao DNA te bao gan ngudi hay khdng phat lvcn bang hda mien dich tren manh sinh thiet gan.Chirng cir nay quan trong va cd vai trd quan trong nhat vi thay tren 90% ciia ngudi ung thu bieu md gan cd lien quan den HBV cd dang tich hem ;,ngoai ra hepadna cd gen X thi HBV mdi gay ung thu gan nguyen phat.(7)
Tdi rat ddng y vdi Anna Suk Feng (8) da viet thay thudc khi dieu tri cho benh nhan VGBMT can dieu tri can xem nhung ky thuat xet nghiem cd trong tay; va chi dam bao vdi benh nhan cd the dieu tri tot VGBMT va se giam tin xuat sang xo gan cdn UTGNP thi chua cd gi chic chan ca.
Xin xem md hinh genome HBV va tang sinh de minh hoa trinh bay cua bai nay.
Tap chi GAN MAT VIET NAM so 13-2010 71
v 6
Tieu the Dane hay virion hoan chinh
Qua trinh sinh trudng cda HBV
72 Tap chi GAN MAT VIET NAM so 13-2010
Tai lieu tham khao
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with and without anti HBsAb implication in the development of hepatoma carcinoma http://wwwhb.advocate.org.news/reports/DD WHBV-2006/Hepatitis 12/20/2006A .3. Ervin Sablon-Fred Shapiro Advance in
molecular diagnosis of HBV infection Inter- national Journal of HBV and drug resistance 2005.2:8-16
4. Scott K Fung and all Management with antiviral resistance Division of Gas- teroenterology University Michigan http://www.natap.org.2004
5. Emnet B Kceefle and all Treatment algory- thm for the management of chronic hepatitis infection.USD guideline update 7/2006Clini- cal gasteroenterology http://herpb.org/patients /treatment algoryhtm summary, html 9/1.2006 6. Anna S Flok. Anna Arbor New antiviral ther-
apy for HBV. Michigan University http://www.mcd.com.hepatitis /case base /lok.
htlm6/14/2005
7. Pham hoang Phiet. Viem gan vims B va Ung thu gan bieu md nguyen phat (Sach UTGNP - NXBYH 2006 Ha van Mao chu bien ) 8. Anna Suk Fong Navigating in the maze of
chronic hepatitis treatment Gasteroenterology 2007 132/1586-1594
