血透患者的慢性丙肝治療

血透患者慢性丙肝的治療 2009-1-20 　　終末期腎病（ESRD）接受血透的患者中丙肝病毒感染是棘手的問題。在血透患者中HCV感染的發生率高於普通人羣，一些傳播途徑被認爲起源與透析中心。血透患者的治療也更復雜，因爲藥代動力學發生改變，並更傾向發生藥物毒性反應，尤其是利巴韋林引起的貧血。關於慢性丙肝且腎移植物健康有功能的患者的臨牀試驗非常少，因爲會帶來移植物排斥的風險。因此，大多數研究關注於ESRD等待腎移植的患者。此外，在這些患者中有利巴韋林禁忌症，許多研究觀察了單藥治療。根據薈萃分析，普通干擾素α治療獲得37%的持續病毒學應答（SVR），聚乙二醇干擾素α單藥治療的SVR率在13%～75%之間。在一些小型研究開始監測血漿利巴韋林濃度或血紅蛋白水平，以助聯合治療的開展。並根據這些研究的結果我們複習了治療指南和推薦策略以幫助患者獲得最佳治療。結論：對於ESRD伴慢性丙肝的患者仍缺乏最有效治療選擇的結果。在很多患者中能獲得SVR，但基於干擾素α治療的耐受性較差仍是一個顧慮，因此爲了維持依從性應推行緊密的支持性醫護。 Hepatology. 2008 Nov;48(5):1690-9.Treatment of chronic hepatitis C in hemodialysis patients.Berenguer M. Hepatogastroenterology Service, Hospital La Fe, Facultad de Medicina de la Universidad de Valencia, Valencia, Spain. Hepatitis C virus (HCV) infection is especially problematic in patients with end-stage renal disease (ESRD) who are undergoing hemodialysis. Rates of HCV infection are higher among hemodialysis patients than in the general population, and several routes of transmission are thought to stem from the dialysis unit. Management of chronic hepatitis C is also more complicated in hemodialysis patients because of altered pharmacokinetics and a predisposition for drug-related toxicity, particularly ribavirin-induced anemia. Clinical trials of patients with chronic hepatitis C and healthy, functioning kidney grafts are rare because of the inherent dangers of graft rejection. As a result, most studies in patients with ESRD have focused on patients waiting for a kidney transplant. Additionally, because ribavirin is contraindicated in this patient population, many studies have examined monotherapy treatments. According to meta-analyses, conventional interferon alfa treatment yields a sustained virological response (SVR) rate of 37%, whereas studies of pegylated interferon alfa monotherapy have yielded SVR rates between 13% and 75%. Several small studies have also used the monitoring of ribavirin plasma concentrations or hemoglobin levels to facilitate the use of combination therapy. In light of the results from these clinical trials, we herein review treatment guidelines and recommend strategies to help optimize the treatment of patients with ESRD. CONCLUSION: There remains a lack of clarity surrounding the most effective treatment options for patients with chronic hepatitis C and ESRD. Treatment can be effective with many patients attaining SVR; however, unfavorable tolerability with interferon alfa-based therapy remains a concern and thus close supportive care should be aggressively pursued to help maintain adherence.