补肾清透治疗慢性乙型肝炎病毒携带者随机对照研究
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摘要
背景和目的
乙型肝炎病毒(HBV)感染是危及全球人类健康的疾病。该病预后差,常合并多种并发症,如肝硬化腹水、上消化道出血、肝性脑病,甚至进展为肝癌,因而严重影响人民身体健康及生活质量。近年来,随着长效干扰素与核苷类药物的运用,使部分(约30%患者出现持续的病毒应答)患者病情得到控制或改善,但慢性乙型肝炎携带者,处于免疫耐受期,如何治疗,目前尚没有治疗指导意见,主要原因对治疗反应差。中医中药通过自身的优势,在治疗乙型肝炎携带者临床治疗中积累了大量的经验。
本研究在导师数十载临床治疗经验的基础上,总结出乙型肝炎与肾虚本质的关系,临床采用“补肾清透解毒“治疗方法,对其临床诊治中医辨证为肝郁肾虚慢性乙型肝炎携带者进行临床随机对照试验。
方法
1.慢性乙型肝炎病毒携带者体质与临床证候3000例流行病学调查；
2.通过纳入300例慢性乙型肝炎携带者,年龄在30岁以上者,即目前认为临床高危不良结局的患者进行临床干预；
3.采用多中心、随机、双盲、安慰剂对照,按2：1的比例,将临床结局不良高危的患者分为治疗组与对照组,疗程52周。对照组用安慰剂对照,试验组为补肾清透解毒颗粒冲剂。
4.随机化和分药管理：病人被随机化分2组,即干预与非干预。本研究的双盲药品有2套盒,1套盒中有补肾清透解毒颗粒冲剂,另1套盒为外观与补肾清透解毒颗粒冲剂相同的安慰剂。
5.治疗方案与管理程序：补肾清透解毒方组成：印度叶下珠30g、菟丝子10g、仙灵脾30g、女贞子15g、旱莲草15g、柴胡10g、白芍10g、枳实10g、桃仁10g、甘草5g、虎杖15g,安慰剂是采用5%的霍香与药品增加剂组成的,外观与味道与试验药品相似,每日1剂,分两次服用。治疗52周。
6.疗效观察
主要疗效指标：(1)服药后第12、24、36、52周检测血清HBV-DNA,方法采用PCR HBVDNA,仪器采用罗氏COBAS Ampliprep TaqMan48系统阴性值HBV-DNA<60IU/ml);(2)服药后第12、24、36、52周检测血清乙型肝炎标志物HBsAg、 HBeAg定量,方法采用雅培公司ARCHITECT i2000sr系统化学发光免疫法。
次要疗效指标：(1)肝纤四项指标：透明质酸(LN)、层粘蛋白(HA)、四型胶原(C-Ⅳ)、前三型胶原(P-III-P);(2)免疫学指标：血清细胞因子TNF-α, IL-2、 IL-4、 IL-10、 IFN γ,采用ELISE方法检测。(3)肝组织学变化情况：入组患者全部肝穿,52周时肝穿人数不少于纳入治疗总人数的25%。
结果
1.慢性乙型肝炎病毒携带者的中医证候与体质分布规律
全国共有18家单位参加调查,发出调查表3000份,收回有效调查表2837份。慢性乙型肝炎中医证候主要为脾肾虚占52.31%,肝气郁结16.92%,其中肾虚肝郁48.82%,合计脾肾虚肝郁69.23%。共2837份中医体质表,调查结果与中医证候相似,结果其中肾虚质56%。
共调查检测慢性乙肝病毒携带者2474例基因型以B型(占49.92%)、C型(占49.35%)为主,少数为D型(占0.73%),证实了我国慢乙肝病毒携带者感染HBV基因型以B、C型为主。
2.高危不良结局患者补肾清透随机对为治疗结果
研究入组病例情况：A组为补肾清透组200例、B组为补肾清透安慰剂组100例。病例剔除及脱落情况：A组12周时脱落6例、24周时脱落7例、36周时脱落9例,完成52周治疗有效病例共191例；B组12周时脱落1例、24周时脱落1例、36周时脱落6例,完成52周治疗有效病例共94例。最终进入疗效统计数为：A组191例、B组94例。
2.1两组治疖对慢性乙肝病毒携带者血清HBV DNA的影响
(1)两组治疗后血清HBV DNA较基线平均下降水平
治疗52W时,A、B组分别较基线平均下降：0.801lg、0.0941g,其中A组治疗前后比较有统计学差异,P＜0.01,而B组治疗前后比较无统计学差异,P＞0.05。治疗24W后,A、B两组之间无差异：治疗52W时,A组与B组比较,P＜0.01。
(2)两组治疗后血清HBV DNA较基线下降分层分析
治疗52W时,HBV DNA较基线下降＞11g比例分别为：A组41.36%(79/191)、B组15.96%(15/94),A组与B组比较,P＜0.01(X2=18.3926)；HBV DNA较基线下降＞21g比例分别为：A组19.37%(37/191)、B组4.26%(4/94),A组与B组比较,P<0.001(X2=11.1189)；HBV DNA较基线下降＞31g比例分别为：A组9.95%(19/191)、B组3.19%(3/94),两组间比较无统计学差异(P＞0.05)；HBV DNA阴转比例分别为：A组1.57%(3/191)、B组0.52%(1/94),两组间比较无统计学差异(P＞0.05)。
(3)两组治疗52W时血清HBV DNA小于105IU/ml比例
治疗52W时HBV DNA小于105IU/ml比例分别为：A组10.99%(21/191),B组3.19%(3/94)。A组与B组比较有统计学差异,P＜0.05(X2=4.0136,P=0.0451)
2.2两组治疗对慢性乙肝病毒携带者血清HBeAg的影响
(1)两组治疗前后血清HBeAg均值下降水平
治疗24W时,A、B组HBeAg均值分别为：1084.84S/Co、1072.23S/Co,其中A组与治疗前比较有统计学差异,P＜0.05(P=0.0198),B组与治疗前比较无统计学差异,P＞0.05；两组之间比较无统计学差异,P＞0.05。
治疗36W时,A、B、组HBeAg均值分别为：978.75S/Co、1083.43S/Co、,其中A组与治疗前比较均有统计学差异,P＜0.001,而B组与治疗前比较无统计学差异,P＞0.05。A组与B组比较,P＜0.05(P=0.0249)。
治疗52W时,A、B、组HBeAg均值分别为：882.51S/Co,1074.32S/Co,其中A组与治疗前比较均有统计学差异,P＜0.001,而B组与治疗前比较无统计学差异,P＞0.05。A组与B组比较,P＜0.01(P=0.0054)。
(2)两组治疗后血清HBeAg阴转情况
治疗52W时,HBeAg阴转比例分别为：A组3.66%(7/191),B组4.26%(4／94),两组之间比较无统计学差异,P＞0.05。
治疗52W时HBeAg血清转换(HBeAg-/HBeAb+)比例分别为：A组3.66%(7／191),B组3.19%(3／94),两组之间比较无统计学差异,P＞0.05。
2.3.两组治疗对慢性乙肝病毒携带者血清标志物HBsAg的影响
(1)两组治疗后HBsAg较基线平均下降水平
治疗12W时,A、B组分别较基线平均下降：0.1461g、0.0941g,其中A组与治疗前比较有统计学意义,P＜0.05(P=0.0407)；而B治疗前比较无统计学差异,P＞0.05。
治疗24W时,A、B分别较基线平均下降：0.1641g、0.0561g,其中A组与治疗前比较有统计学意义,P＜0.05(P=0.0173)；而B组与治疗前比较无统计学差异,P＞0.05。
治疗36W时,A、B组分别较基线平均下降：0.2871g、0.1071g,其中A组与治疗前比较有统计学意义,P＜0.01(P=0.0001)；而B组与治疗前比较无统计学差异,P＞0.05。
治疗52W时,A、B组分别较基线平均下降：0.4281g、0.1401g其中A组与治疗前比较均有统计学意义,P＜0.01(P=O.0001)；而B组与治疗前比较无统计学差异,P＞0.05。
(2)两组治疗后血清HBsAg较基线下降分层分析
治疗36W时,HBsAg较基线下降＞0.51g比例分别为：A组14.66%(28/191)、B组6.38%(6/94),A组与B组比较有统计学差异,P＜0.05(X2=4.1074,P=0.0427),HBsAg较基线下降＞11g比例分别为：A组6.81%(13/191)、B组1.06%(1/94),两组间比较无统计学差异(P＞0.05)；HBsAg较基线下降>21g比例分别为：A组1.05%(2/191)、B组0.00%(0/94),两组间比较无统计学差异(P＞0.05)；HBsAg阴转比例分别为：A组0.00%(1/191)、B组0.00%(0/94),两组间比较无统计学差异(P＞0.05)。
治疗52W时,HBsAg较基线下降＞0.51g比例分别为：A组27.23%(52/191)、B组8.51%(8／94),A组与B组比较有统计学差异,P＜0.01(X2=13.2748,P=0.000269);HBsAg较基线下降>l1g比例分别为：A组10.47%(20／191)、B组4.26%(4／94),两组间比较无统计学差异(P=0.07)；HBsAg较基线下降＞21g比例分别为：A组2.09%(4/191)、B组1.06%(1/94),各组间比较无统计学差异(P＞0.05)；HBsAg阴转比例分别为：A组0.52%(1/191)、B组0.00%(0/94),各组间比较无统计学差异(P＞0.05)。
2.4肝脏组织学变化
入组两组患者共285人,其中有26%组织学有活动性炎症(≥2级)和／或纤维化(≥2期)者。用补肾清透方治疗52周后,二次肝穿共73例,占入组的25.6%,其中有10例(13%)患者肝脏的炎症与纤维化,以及免疫组化HBsAg表达,治疗后有显着下降,3例有加重,60例变化不明显。
2.5两组治疗对慢性乙肝病毒携带者血清免疫因子的影响及其与HBV DNA的相关性
(1)两组治疗对慢性乙肝病毒携带者血清免疫因子的影响
两组治疗前细胞因子IL-2, IL-4、IL-10、 IFN-γ TNF-a比较,差异均无显着性意义,P＞0.05,可比性好；治疗后各细胞因子的变化说明：补肾清透方能大幅提高患者的IL-2水平(分别提高60.4%、75.7%)、IFN-γ水平(分别提高37.4%、60.1%)；大幅降低IL-4、IL-10的水平(42.1%-48.4%)。安慰剂组对各细胞因子几乎无影响。除补肾清透组TNF-a治疗后变化值外,补肾清透治疗组对IL-2、 IL-4、 IL-10、 IFN-γ、TNF-a的改善与安慰剂组比较,差异均有显着性意义,P＜0.05。
补肾清透方治疗组HBV DNA下降大于11g患者比下降≤11g的患者IL-2、IFN-Y升高,差异有统计学意义。IL-4、IL-10、TNF-a组间比较,差异无统计学意义。
(2)治疗组血清HBV DNA下降与细胞因子变化的相关性
治疗组HBV DNA下降与IL-2呈中度相关(Pearson相关系数为-0.417,P＜0.01),与INF-γ呈弱相关(Pearson相关系数为-0.231,P＜0.01)；全部患者HBV DNA下降与IL-2呈中度相关(Pearson相关系数为-0.425,P＜0.01),与INF-Y呈弱相关(Pearson相关系数为-0.266,P＜0.01)。全部HBV DNA下降大于1个lg的患者HBV DNA下降与IL2呈中度相关(Pearson相关系数为-0.428,P＜0.01),与INF-γ呈极弱相关(Pearson相关系数为-0.151,P＜0.01)。
结论
大量研究表明,对于ALT<1ULT的慢性乙肝病毒携带者,仍然有疾病进展的风险,但口前各国指南,并无具体治疗指导意见,对此进行中医药临床研究,并以补肾清透法治疗,得到以下结果
1.慢性乙肝病毒携带者的中医分布规律与体质调查显示,以肾虚、脾虚、肝郁为主,亦有肝胃不和,湿热中阻等,与我们提出的“肾虚”是慢性乙型肝炎携带本质是一致的。
2.补肾清透法能有效抑制慢性乙型肝炎HBVDNA与病毒标志物的表达,甚至肝组织改善,但52W的疗程明显不足,仍需要延长疗程,提高疗效。
3.补肾清透法透过升高IL-2, IFN-y,降低IL-4, IL-10,来抑制HBV DNA复制,其抗乙型肝炎病毒作用是通过调整机体免疫功能,改变免疫耐受状态来实现的。为开发有效防治慢性乙型肝炎病毒携带者病情进展的中药新药提供了坚实的临床证据。
Background&Aims
The infection of Hepatitis B virus (HBV) is endangering the world's health. The disease prognosis is poor, often with a variety of complications, such as cirrhosis ascites, upper gastrointestinal bleeding, hepatic encephalopathy, or even progress for liver cancer, and it has become social problems which seriously affect people's health and quality of life. In recent years, with the using of peginterferon and nucleoside drugs, the diseases of some patients(about30%appear with e antigen seroconversion) are under control or improved. But how to treat those chronic hepatitis B virus carriers who are in the immune-tolerant phase, no treatment guidelines could be available at present, mainly for its poor treatment respond. Traditional Chinese medicine has accumulated much experience in the treatment of hepatitis B carriers by making good use of their own advantages.
Based on the mentor's experience of clinical treatment for decades, this study has summarized the relation between hepatitis B and the deficiency of kidney essence. And with "Kidney tonifying and detoxification" treatment method, those chronic hepatitis B carriers who are "kidney deficiency and liver stagnation type" in TCM syndrome differentiation joined the clinical randomized controlled trial.
Methods
1.3000cases of physique and clinical syndrome of epidemiological survey in chronic hepatitis B virus carriers
2.300chronic hepatitis B carriers,30years old or more, patients now thought at high clinical outcomes risk were intaked for clinical intervention.
3. A multi-center, randomized, double-blind, placebo-controlled test of52weeks was conducted and patients of high-risk clinical outcome were divided into treatment group and control group, according to a2:1ratio. The placebo group was to compare with the treatment group of "Kidney tonifying and detoxification granule"
4. Random and points medicine management:patients were divided into two groups in the random, namely the intervention and the non-intervention. There were two sets of double-blind drugs box, one was filled with "Kidney tonifying and detoxification granule",the other was placebo of the same appearance
5. Treatment and management program:"Kidney tonifying and detoxification medicinal herbs"(basic compose of medicine:India Phyllanthus urinaria L30g, Cuscutae Semen10g, Herba Epimedii30g, Glossy Privet Fruit15g, Herba Ecliptae15g, radix bupleuri10g, White peony root10g, Fructus Aurantii Immaturus10g, semen persicae10g, liquorice5g, rhizoma polygoni cuspidate15g) test drug or controlled drugs(placebo), daily a dose, twice taking. Treatment lasts52weeks.
6. Curative effects
Main efficacy index:(1)12,24, and36,52weeks after taking medicine testing the serum HBV DNA by PCR method with COBAS Ampliprep TaqMan48system of Hoffmann-La Roche (negative value HBV DNA<60copies/ml);(2)12,24, and36,52weeks after taking medicine testing the serum hepatitis B markers HBsAg, HBeAg quantitative by chemical luminescence immunoassay method, that is the ARCHITECT i2000sr system of Abbott Laboratories.
Secondary efficacy index:(1)four indexes of liver fibrosis:hyaluronic acid(HA), laminin(LN), collagen IV(C-IV), amino terminal of procollagen type III peptide(P-Ⅲ-P);(2)immunological indexes:serum cell factors TNF-a, IL-2, IL-4, IL-10, IFN-γ, detected by the ELISE method.(3) liver histology change:all patients needed to do a liver biopsy, and it should not be less than50%of the total treatment number untill the52th weeks.
Results
1. The distribution law of TCM syndrome and physique in chronic hepatitis B virus carriers
There were18institutions who participated in the survey throughout the country.
All together3000sets of questionnaires were issued and out of that there were2837effective returns.The main TCM syndrome of chronic hepatitis B are syndrome of deficiency of the spleen and kidney (accounting for52.31%) and liver qi stagnation (accounting for16.92%).Among them, syndrome of kidney-asthenia and liver depression accounts for48.82%, and that is69.23%in totall when adding both of the syndrome of deficiency of the spleen and kidney and liver depression up. The results of the survey, according to the total2837questionnaires in which the syndrome of deficiency of kidney according for56%, were similar to that of the TCM syndrome.
The main genotype of the total2474cases of chronic hepatitis B virus carriers tested in the survey were type B(49.92%) and C(49.35%),while type D only accounted for a minority(0.73%). Therefore, it confirmed that type Band C were the main genotype of chronic hepatitis B virus carriers in our country.
2. The treatment results of randomized controlled test with "Kidney tonifying and detoxification"in patients of high risk and adverse outcome
Patients intaked:group A200cases was to treat with Kidney tonifying and detoxification granule, group B100cases was the placebo group. Patients excluded and shed:In group A6cases were shed at6weeks,7at24weeks,9at36weeks, and a total of191effective cases who completed the treatment at52weeks. In group B1case was shed at12weeks,1at24weeks,6at36weeks, and a total of94effective cases that completed the treatment at52weeks. So the finall number of patients who were counted into curative effect were:group A of191, group B94cases.
2.1Therapeutic effect on influence of serum HBV DNA in chronic hepatitis B virus carriers
(1) The average descent of serum HBV DNA after treatment compared to the baseline in both group
When treating for52weeks, compared to the baseline, group A and B were respectively declined:0.8011g,0.0941g. For group A, it was statistically significant (P<0.01), when compared before and after treatment;while for group B, there were no significant differences (P>0.05). There were no differences between group A and B after24weeks'treatment; When it came to the52weeks, the two group were compared (P<0.01).
(2) Stratified analyses of the decline extent of serum HBV DNA after treatment (HBV DNA down>1lg,>2lg,>3lg, and the proportion of HBV DNA negative conversion),when compared to the baseline
When treating for52weeks, compared to the baseline, the proportion of HBV DNA down>1lg were respectively for:group A of41.36%(79/191), group B15.96%(15/94), that was P<0.01(x2=18.3926)when compared; The proportion of HBV DNA down>2lg were respectively for:group A of19.37%(37/191), group B4.26%(4/94), that was P<0.001(x2=11.1189); The proportion of HBV DNA down>3lg were respectively for:group A of9.95%(19/191), group B3.19%(3/94), and the comparison between were no statistical difference (P>0.05); The proportion of HBV DNA negative conversion were respectively for:group A of1.57%(3/191), group B0.52%(1/94), and there were no significant differences between groups (P>0.05).
(3) The proportion of serum HBV DNA less than105IU/ml in each group when treating for52weeks
When treating for52weeks, the proportion of serum HBV DNA less than105IU/ml were respectively for:group A of8.90%(17/191), group B4.26%(4/94), that was P>0.05(x2=2.314, P=0.128)when compared A with B. There were no significant differences between groups(P>0.05).
2.2Therapeutic effect on influence of serum markers HBeAg for chronic hepatitis B virus carriers of the two group
(1) The average descent of serum HBeAg before and after treatment
When treating for24weeks, the mean HBeAg was respectively for:group A of1084.84S/Co, group B1072.23S/Co. Among them the comparison with baseline were no statistical difference for group A, P<0.05(P=0.0198), while group B there were no significant differences, P>0.05; There were no significant differences between groups, P>0.05.
When treating for36weeks, the mean HBeAg was respectively for:group A of978.75S/Co, group B1083.43S/Co. Among them the comparison with baseline were statistically significant for group A, P<0.001, while for group B there were no significant differences, P>0.05; There were significant differences between groups when compared, P<0.05(P=0.0249).
When treating for52weeks, the mean HBeAg was respectively for:group A of882.51S/Co, group B1074.32S/Co.Among them the comparison with baseline were statistically significant for group A, P<0.001, while group B there were no significant differences, P>0.05; There were significant differences between groups when compared, P<0.01(P=0.0054).
(2) The negative conversion of serum HBeAg after treatment in each group
When treating for52weeks, the negative conversion of serum HBeAg was respectively for:group A of3.66%(7/191), group B4.26%(4/94), and there were no significant differences between groups when compared, P>0.05.
When treating for52weeks, the HBeAg seroconversion(HBeAg-/HBeAb+) was respectively for:group A of3.66%(7/191), group B3.19%(3/94), and there were no significant differences between groups, P>0.05.
2.3Therapeutic effect on influence of serum markers HBsAg for chronic hepatitis B virus carriers in each group
(1)The average descent of serum HBsAg in the two group after treatment compared to the baseline
When treating for12weeks, compared to the baseline, group A and B declined on average was respectively for:0.146lg,0.094lg,Among them group A was statistically significant when compared, P<0.05(P=0.0407); while group B had no significant differences when compared(P>0.05).
When treating for24weeks, compared to the baseline, group A and B declined on average was respectively for:0.164lg,0.056lg,Among them group A was statistically significant when compared, P<0.05(P=0.0173); while group B had no significant differences when compared (P>0.05).
When treating for36weeks, compared to the baseline, group A and B declined on average was respectively for:0.287lg,0.107lg, Among them group A was statistically significant when compared, P<0.05(P=0.0001); while group B had no significant differences when compared (P>0.05).
When treating for52weeks, compared to the basel ine, group A and B decl ined on average was respectively for:0.428lg,0.140lg,Among them group A was statistically significant when compared, P<0.05(P=0.0001); while group B had no significant differences when compared (P>0.05).
(2)Stratified analyses of the decline extent of serum HBsAg after treatment (HBsAg down>0.5lg,>1lg,>2lg, and the proportion of HBsAg negative conversion),when compared to the baseline
When treating for36weeks, compared to the baseline, the serum HBsAg down>0.5lg was respectively for:group A of14.66%(28/191), group B6.38%(6/94), and there were statistical differences between the two groups, P<0.05(x2=4.1074, P=0.0427); the serum HBsAg down>l lg was respectively for:group A of6.81%(13/191), group B1.06%(1/94), and the comparison between were no statistical difference(P>0.05); the serum HBsAg down>2lg was respectively for:group A of1.05%(2/191), group B0.00%(0/94),and the comparison between were no statistical difference(P>0.05); The proportion of HBsAg negative conversion were respectively for:group A of0.00%(0/191), group B0.00%(0/94), and there were no significant differences between groups (P>0.05).
When treating for52weeks, compared to the baseline, the serum HBsAg down>0.5lg was respectively for:group A of27.23%(52/191), group B8.51%(8/94),and there were statistical differences between the two groups, P<0.01(x2=13.2748, P=0.000269); the serum HBsAg down>1lg was respectively for:group A of10.47%(20/191), group B4.26%(4/94), and the comparison between were no statistical difference(P>0.05); the serum HBsAg down>2lg was respectively for:group A of2.09%(4/191), group B1.06%(1/94),and the comparison between were no statistical difference(P>0.05); The proportion of HBsAg negative conversion were respectively for:group A of0.00%(0/191), group B0.00%(0/94), and there were no significant differences between groups (P>0.05).
2.4Liver histology changes
There were a total of285patients in the two group, and among them26%were patients with active inflammation (≥Grade2) and/or fibrosis (≥stage2) in histology. After treating for52weeks with "Kidney tonifying and detoxification medicinal herbs", there were73cases of patients who did liver biopsy twice, accouting for25.6%of the total.In those patients,there were10cases(13%) whose inflammation of the liver, fibrosis stage, and immunohistochemical HBsAg expression decreased significantly after treatment,3patients with exacerbations, and another60cases not changing significantly.
2.5. Therapeutic effect on influence of the serum immune factors in chronic hepatitis B virus carriers and their relevance with HBV DNA
(1) Therapeutic effect on influence of the serum immune factors in chronic hepatitis B virus carriers
When comparing the baseline cytokines IL-2, IL-4, IL-10, IFN-γ, TNF-a of each group, there were no significant differences between groups, P>0.05.Therefore, the model had good comparability. Changes of each cytokines after treatment showed that:the " Kidney tonifying and detoxification medicinal herbs" could greatly improved the level of IL-2(increased by60.4%and75.7%respectively), IFN-Y level (increased by37.4%and60.1%respectively), and greatly reduced IL-4, IL-10level (42.1%-48.4%). The placebo group almost had no influence on cytokines. In addition to the TNF-a value changes, the testing group's improvement of IL-2, IL-4, IL-10, IFN-γ had significant differences compared to the placedo group, P<0.05. When comparing the the testing group's improvement of IL-2, IL-4, IL-10, IFN-γ and TNF-a, the difference was not statistically significant.And the ratio of "Kidney tonifying and detoxification medicinal herbs" was37.4%.
(2) The decline of serum HBV DNA and its relevance with changes of cytokines of the treatment group
The HBV DNA decline of the treatment group was moderate related with IL-2(Pearson correlation coefficient is-0.417, P<0.01), and weak related with INF-γ (Pearson correlation coefficient is-0.231, P<0.01); The HBV DNA decline of all patients was moderate related with IL-2(Pearson correlation coefficient is-0.425, P<.0.01), and weak related with INF-γ (Pearson correlation coefficient is-0.266, P<0.01). All patients with a more than1lg of HBV DNA down was moderate related with IL-2(Pearson correlation coefficient is-0.428, P<0.01), and very weak related with INF-γ (Pearson correlation coefficient is-0.151, P<0.01).
The IL-2, IFN-y level of the "Kidney tonifying and detoxification medicinal herbs" treatment group with a more than1lg of HBV DNA down was higher than that with a no more than1lg of HBV DNA down, and the differences were statistically significant. When comparing IL-4, IL-10, and TNF-a between groups, the difference was not statistically significant.
Conelus ions
Many studies demonstrate that, for those chronic hepatitis B virus carriers with ALT<1ULT, it still has a risk of disease progression, however there are no specific treatment guidelines. Studying and treating it with "Kidney tonifying and detoxification", the results are as follows.
(1) Among TCM syndrome type distribution rule of the chronic hepatitis B virus carriers, the syndrome of kidney deficiency and spleen deficiency are given priority to. What's more, there are also syndrome of incoordination between liver and stomach, damp-heat obstructing in zhong jiqo, etc.
(2) And the main constitutional type are qi-asthenia constitution and Yang-deficiency constitution as for chronic hepatitis B virus carriers.
(3)"Kidney tonifying and detoxification" inhibits the replication of HBV DNA by rising levels of IL-2&IFN-γ, and reducing levels of IL-4&IL-10. And its anti-hepatitis B virus effect is realized by adjusting the body's immune function,as well as improving the immunologic status.It provides the strong clinical evidence in developing traditional Chinese drugs effectively treating and protecting the chronic hepatitis B virus carriers from the progress of the disease.
乙型肝炎病毒(HBV)感染是危及全球人类健康的疾病。该病预后差,常合并多种并发症,如肝硬化腹水、上消化道出血、肝性脑病,甚至进展为肝癌,因而严重影响人民身体健康及生活质量。近年来,随着长效干扰素与核苷类药物的运用,使部分(约30%患者出现持续的病毒应答)患者病情得到控制或改善,但慢性乙型肝炎携带者,处于免疫耐受期,如何治疗,目前尚没有治疗指导意见,主要原因对治疗反应差。中医中药通过自身的优势,在治疗乙型肝炎携带者临床治疗中积累了大量的经验。
本研究在导师数十载临床治疗经验的基础上,总结出乙型肝炎与肾虚本质的关系,临床采用“补肾清透解毒“治疗方法,对其临床诊治中医辨证为肝郁肾虚慢性乙型肝炎携带者进行临床随机对照试验。
方法
1.慢性乙型肝炎病毒携带者体质与临床证候3000例流行病学调查；
2.通过纳入300例慢性乙型肝炎携带者,年龄在30岁以上者,即目前认为临床高危不良结局的患者进行临床干预；
3.采用多中心、随机、双盲、安慰剂对照,按2：1的比例,将临床结局不良高危的患者分为治疗组与对照组,疗程52周。对照组用安慰剂对照,试验组为补肾清透解毒颗粒冲剂。
4.随机化和分药管理：病人被随机化分2组,即干预与非干预。本研究的双盲药品有2套盒,1套盒中有补肾清透解毒颗粒冲剂,另1套盒为外观与补肾清透解毒颗粒冲剂相同的安慰剂。
5.治疗方案与管理程序：补肾清透解毒方组成：印度叶下珠30g、菟丝子10g、仙灵脾30g、女贞子15g、旱莲草15g、柴胡10g、白芍10g、枳实10g、桃仁10g、甘草5g、虎杖15g,安慰剂是采用5%的霍香与药品增加剂组成的,外观与味道与试验药品相似,每日1剂,分两次服用。治疗52周。
6.疗效观察
主要疗效指标：(1)服药后第12、24、36、52周检测血清HBV-DNA,方法采用PCR HBVDNA,仪器采用罗氏COBAS Ampliprep TaqMan48系统阴性值HBV-DNA<60IU/ml);(2)服药后第12、24、36、52周检测血清乙型肝炎标志物HBsAg、 HBeAg定量,方法采用雅培公司ARCHITECT i2000sr系统化学发光免疫法。
次要疗效指标：(1)肝纤四项指标：透明质酸(LN)、层粘蛋白(HA)、四型胶原(C-Ⅳ)、前三型胶原(P-III-P);(2)免疫学指标：血清细胞因子TNF-α, IL-2、 IL-4、 IL-10、 IFN γ,采用ELISE方法检测。(3)肝组织学变化情况：入组患者全部肝穿,52周时肝穿人数不少于纳入治疗总人数的25%。
结果
1.慢性乙型肝炎病毒携带者的中医证候与体质分布规律
全国共有18家单位参加调查,发出调查表3000份,收回有效调查表2837份。慢性乙型肝炎中医证候主要为脾肾虚占52.31%,肝气郁结16.92%,其中肾虚肝郁48.82%,合计脾肾虚肝郁69.23%。共2837份中医体质表,调查结果与中医证候相似,结果其中肾虚质56%。
共调查检测慢性乙肝病毒携带者2474例基因型以B型(占49.92%)、C型(占49.35%)为主,少数为D型(占0.73%),证实了我国慢乙肝病毒携带者感染HBV基因型以B、C型为主。
2.高危不良结局患者补肾清透随机对为治疗结果
研究入组病例情况：A组为补肾清透组200例、B组为补肾清透安慰剂组100例。病例剔除及脱落情况：A组12周时脱落6例、24周时脱落7例、36周时脱落9例,完成52周治疗有效病例共191例；B组12周时脱落1例、24周时脱落1例、36周时脱落6例,完成52周治疗有效病例共94例。最终进入疗效统计数为：A组191例、B组94例。
2.1两组治疖对慢性乙肝病毒携带者血清HBV DNA的影响
(1)两组治疗后血清HBV DNA较基线平均下降水平
治疗52W时,A、B组分别较基线平均下降：0.801lg、0.0941g,其中A组治疗前后比较有统计学差异,P＜0.01,而B组治疗前后比较无统计学差异,P＞0.05。治疗24W后,A、B两组之间无差异：治疗52W时,A组与B组比较,P＜0.01。
(2)两组治疗后血清HBV DNA较基线下降分层分析
治疗52W时,HBV DNA较基线下降＞11g比例分别为：A组41.36%(79/191)、B组15.96%(15/94),A组与B组比较,P＜0.01(X2=18.3926)；HBV DNA较基线下降＞21g比例分别为：A组19.37%(37/191)、B组4.26%(4/94),A组与B组比较,P<0.001(X2=11.1189)；HBV DNA较基线下降＞31g比例分别为：A组9.95%(19/191)、B组3.19%(3/94),两组间比较无统计学差异(P＞0.05)；HBV DNA阴转比例分别为：A组1.57%(3/191)、B组0.52%(1/94),两组间比较无统计学差异(P＞0.05)。
(3)两组治疗52W时血清HBV DNA小于105IU/ml比例
治疗52W时HBV DNA小于105IU/ml比例分别为：A组10.99%(21/191),B组3.19%(3/94)。A组与B组比较有统计学差异,P＜0.05(X2=4.0136,P=0.0451)
2.2两组治疗对慢性乙肝病毒携带者血清HBeAg的影响
(1)两组治疗前后血清HBeAg均值下降水平
治疗24W时,A、B组HBeAg均值分别为：1084.84S/Co、1072.23S/Co,其中A组与治疗前比较有统计学差异,P＜0.05(P=0.0198),B组与治疗前比较无统计学差异,P＞0.05；两组之间比较无统计学差异,P＞0.05。
治疗36W时,A、B、组HBeAg均值分别为：978.75S/Co、1083.43S/Co、,其中A组与治疗前比较均有统计学差异,P＜0.001,而B组与治疗前比较无统计学差异,P＞0.05。A组与B组比较,P＜0.05(P=0.0249)。
治疗52W时,A、B、组HBeAg均值分别为：882.51S/Co,1074.32S/Co,其中A组与治疗前比较均有统计学差异,P＜0.001,而B组与治疗前比较无统计学差异,P＞0.05。A组与B组比较,P＜0.01(P=0.0054)。
(2)两组治疗后血清HBeAg阴转情况
治疗52W时,HBeAg阴转比例分别为：A组3.66%(7/191),B组4.26%(4／94),两组之间比较无统计学差异,P＞0.05。
治疗52W时HBeAg血清转换(HBeAg-/HBeAb+)比例分别为：A组3.66%(7／191),B组3.19%(3／94),两组之间比较无统计学差异,P＞0.05。
2.3.两组治疗对慢性乙肝病毒携带者血清标志物HBsAg的影响
(1)两组治疗后HBsAg较基线平均下降水平
治疗12W时,A、B组分别较基线平均下降：0.1461g、0.0941g,其中A组与治疗前比较有统计学意义,P＜0.05(P=0.0407)；而B治疗前比较无统计学差异,P＞0.05。
治疗24W时,A、B分别较基线平均下降：0.1641g、0.0561g,其中A组与治疗前比较有统计学意义,P＜0.05(P=0.0173)；而B组与治疗前比较无统计学差异,P＞0.05。
治疗36W时,A、B组分别较基线平均下降：0.2871g、0.1071g,其中A组与治疗前比较有统计学意义,P＜0.01(P=0.0001)；而B组与治疗前比较无统计学差异,P＞0.05。
治疗52W时,A、B组分别较基线平均下降：0.4281g、0.1401g其中A组与治疗前比较均有统计学意义,P＜0.01(P=O.0001)；而B组与治疗前比较无统计学差异,P＞0.05。
(2)两组治疗后血清HBsAg较基线下降分层分析
治疗36W时,HBsAg较基线下降＞0.51g比例分别为：A组14.66%(28/191)、B组6.38%(6/94),A组与B组比较有统计学差异,P＜0.05(X2=4.1074,P=0.0427),HBsAg较基线下降＞11g比例分别为：A组6.81%(13/191)、B组1.06%(1/94),两组间比较无统计学差异(P＞0.05)；HBsAg较基线下降>21g比例分别为：A组1.05%(2/191)、B组0.00%(0/94),两组间比较无统计学差异(P＞0.05)；HBsAg阴转比例分别为：A组0.00%(1/191)、B组0.00%(0/94),两组间比较无统计学差异(P＞0.05)。
治疗52W时,HBsAg较基线下降＞0.51g比例分别为：A组27.23%(52/191)、B组8.51%(8／94),A组与B组比较有统计学差异,P＜0.01(X2=13.2748,P=0.000269);HBsAg较基线下降>l1g比例分别为：A组10.47%(20／191)、B组4.26%(4／94),两组间比较无统计学差异(P=0.07)；HBsAg较基线下降＞21g比例分别为：A组2.09%(4/191)、B组1.06%(1/94),各组间比较无统计学差异(P＞0.05)；HBsAg阴转比例分别为：A组0.52%(1/191)、B组0.00%(0/94),各组间比较无统计学差异(P＞0.05)。
2.4肝脏组织学变化
入组两组患者共285人,其中有26%组织学有活动性炎症(≥2级)和／或纤维化(≥2期)者。用补肾清透方治疗52周后,二次肝穿共73例,占入组的25.6%,其中有10例(13%)患者肝脏的炎症与纤维化,以及免疫组化HBsAg表达,治疗后有显着下降,3例有加重,60例变化不明显。
2.5两组治疗对慢性乙肝病毒携带者血清免疫因子的影响及其与HBV DNA的相关性
(1)两组治疗对慢性乙肝病毒携带者血清免疫因子的影响
两组治疗前细胞因子IL-2, IL-4、IL-10、 IFN-γ TNF-a比较,差异均无显着性意义,P＞0.05,可比性好；治疗后各细胞因子的变化说明：补肾清透方能大幅提高患者的IL-2水平(分别提高60.4%、75.7%)、IFN-γ水平(分别提高37.4%、60.1%)；大幅降低IL-4、IL-10的水平(42.1%-48.4%)。安慰剂组对各细胞因子几乎无影响。除补肾清透组TNF-a治疗后变化值外,补肾清透治疗组对IL-2、 IL-4、 IL-10、 IFN-γ、TNF-a的改善与安慰剂组比较,差异均有显着性意义,P＜0.05。
补肾清透方治疗组HBV DNA下降大于11g患者比下降≤11g的患者IL-2、IFN-Y升高,差异有统计学意义。IL-4、IL-10、TNF-a组间比较,差异无统计学意义。
(2)治疗组血清HBV DNA下降与细胞因子变化的相关性
治疗组HBV DNA下降与IL-2呈中度相关(Pearson相关系数为-0.417,P＜0.01),与INF-γ呈弱相关(Pearson相关系数为-0.231,P＜0.01)；全部患者HBV DNA下降与IL-2呈中度相关(Pearson相关系数为-0.425,P＜0.01),与INF-Y呈弱相关(Pearson相关系数为-0.266,P＜0.01)。全部HBV DNA下降大于1个lg的患者HBV DNA下降与IL2呈中度相关(Pearson相关系数为-0.428,P＜0.01),与INF-γ呈极弱相关(Pearson相关系数为-0.151,P＜0.01)。
结论
大量研究表明,对于ALT<1ULT的慢性乙肝病毒携带者,仍然有疾病进展的风险,但口前各国指南,并无具体治疗指导意见,对此进行中医药临床研究,并以补肾清透法治疗,得到以下结果
1.慢性乙肝病毒携带者的中医分布规律与体质调查显示,以肾虚、脾虚、肝郁为主,亦有肝胃不和,湿热中阻等,与我们提出的“肾虚”是慢性乙型肝炎携带本质是一致的。
2.补肾清透法能有效抑制慢性乙型肝炎HBVDNA与病毒标志物的表达,甚至肝组织改善,但52W的疗程明显不足,仍需要延长疗程,提高疗效。
3.补肾清透法透过升高IL-2, IFN-y,降低IL-4, IL-10,来抑制HBV DNA复制,其抗乙型肝炎病毒作用是通过调整机体免疫功能,改变免疫耐受状态来实现的。为开发有效防治慢性乙型肝炎病毒携带者病情进展的中药新药提供了坚实的临床证据。
Background&Aims
The infection of Hepatitis B virus (HBV) is endangering the world's health. The disease prognosis is poor, often with a variety of complications, such as cirrhosis ascites, upper gastrointestinal bleeding, hepatic encephalopathy, or even progress for liver cancer, and it has become social problems which seriously affect people's health and quality of life. In recent years, with the using of peginterferon and nucleoside drugs, the diseases of some patients(about30%appear with e antigen seroconversion) are under control or improved. But how to treat those chronic hepatitis B virus carriers who are in the immune-tolerant phase, no treatment guidelines could be available at present, mainly for its poor treatment respond. Traditional Chinese medicine has accumulated much experience in the treatment of hepatitis B carriers by making good use of their own advantages.
Based on the mentor's experience of clinical treatment for decades, this study has summarized the relation between hepatitis B and the deficiency of kidney essence. And with "Kidney tonifying and detoxification" treatment method, those chronic hepatitis B carriers who are "kidney deficiency and liver stagnation type" in TCM syndrome differentiation joined the clinical randomized controlled trial.
Methods
1.3000cases of physique and clinical syndrome of epidemiological survey in chronic hepatitis B virus carriers
2.300chronic hepatitis B carriers,30years old or more, patients now thought at high clinical outcomes risk were intaked for clinical intervention.
3. A multi-center, randomized, double-blind, placebo-controlled test of52weeks was conducted and patients of high-risk clinical outcome were divided into treatment group and control group, according to a2:1ratio. The placebo group was to compare with the treatment group of "Kidney tonifying and detoxification granule"
4. Random and points medicine management:patients were divided into two groups in the random, namely the intervention and the non-intervention. There were two sets of double-blind drugs box, one was filled with "Kidney tonifying and detoxification granule",the other was placebo of the same appearance
5. Treatment and management program:"Kidney tonifying and detoxification medicinal herbs"(basic compose of medicine:India Phyllanthus urinaria L30g, Cuscutae Semen10g, Herba Epimedii30g, Glossy Privet Fruit15g, Herba Ecliptae15g, radix bupleuri10g, White peony root10g, Fructus Aurantii Immaturus10g, semen persicae10g, liquorice5g, rhizoma polygoni cuspidate15g) test drug or controlled drugs(placebo), daily a dose, twice taking. Treatment lasts52weeks.
6. Curative effects
Main efficacy index:(1)12,24, and36,52weeks after taking medicine testing the serum HBV DNA by PCR method with COBAS Ampliprep TaqMan48system of Hoffmann-La Roche (negative value HBV DNA<60copies/ml);(2)12,24, and36,52weeks after taking medicine testing the serum hepatitis B markers HBsAg, HBeAg quantitative by chemical luminescence immunoassay method, that is the ARCHITECT i2000sr system of Abbott Laboratories.
Secondary efficacy index:(1)four indexes of liver fibrosis:hyaluronic acid(HA), laminin(LN), collagen IV(C-IV), amino terminal of procollagen type III peptide(P-Ⅲ-P);(2)immunological indexes:serum cell factors TNF-a, IL-2, IL-4, IL-10, IFN-γ, detected by the ELISE method.(3) liver histology change:all patients needed to do a liver biopsy, and it should not be less than50%of the total treatment number untill the52th weeks.
Results
1. The distribution law of TCM syndrome and physique in chronic hepatitis B virus carriers
There were18institutions who participated in the survey throughout the country.
All together3000sets of questionnaires were issued and out of that there were2837effective returns.The main TCM syndrome of chronic hepatitis B are syndrome of deficiency of the spleen and kidney (accounting for52.31%) and liver qi stagnation (accounting for16.92%).Among them, syndrome of kidney-asthenia and liver depression accounts for48.82%, and that is69.23%in totall when adding both of the syndrome of deficiency of the spleen and kidney and liver depression up. The results of the survey, according to the total2837questionnaires in which the syndrome of deficiency of kidney according for56%, were similar to that of the TCM syndrome.
The main genotype of the total2474cases of chronic hepatitis B virus carriers tested in the survey were type B(49.92%) and C(49.35%),while type D only accounted for a minority(0.73%). Therefore, it confirmed that type Band C were the main genotype of chronic hepatitis B virus carriers in our country.
2. The treatment results of randomized controlled test with "Kidney tonifying and detoxification"in patients of high risk and adverse outcome
Patients intaked:group A200cases was to treat with Kidney tonifying and detoxification granule, group B100cases was the placebo group. Patients excluded and shed:In group A6cases were shed at6weeks,7at24weeks,9at36weeks, and a total of191effective cases who completed the treatment at52weeks. In group B1case was shed at12weeks,1at24weeks,6at36weeks, and a total of94effective cases that completed the treatment at52weeks. So the finall number of patients who were counted into curative effect were:group A of191, group B94cases.
2.1Therapeutic effect on influence of serum HBV DNA in chronic hepatitis B virus carriers
(1) The average descent of serum HBV DNA after treatment compared to the baseline in both group
When treating for52weeks, compared to the baseline, group A and B were respectively declined:0.8011g,0.0941g. For group A, it was statistically significant (P<0.01), when compared before and after treatment;while for group B, there were no significant differences (P>0.05). There were no differences between group A and B after24weeks'treatment; When it came to the52weeks, the two group were compared (P<0.01).
(2) Stratified analyses of the decline extent of serum HBV DNA after treatment (HBV DNA down>1lg,>2lg,>3lg, and the proportion of HBV DNA negative conversion),when compared to the baseline
When treating for52weeks, compared to the baseline, the proportion of HBV DNA down>1lg were respectively for:group A of41.36%(79/191), group B15.96%(15/94), that was P<0.01(x2=18.3926)when compared; The proportion of HBV DNA down>2lg were respectively for:group A of19.37%(37/191), group B4.26%(4/94), that was P<0.001(x2=11.1189); The proportion of HBV DNA down>3lg were respectively for:group A of9.95%(19/191), group B3.19%(3/94), and the comparison between were no statistical difference (P>0.05); The proportion of HBV DNA negative conversion were respectively for:group A of1.57%(3/191), group B0.52%(1/94), and there were no significant differences between groups (P>0.05).
(3) The proportion of serum HBV DNA less than105IU/ml in each group when treating for52weeks
When treating for52weeks, the proportion of serum HBV DNA less than105IU/ml were respectively for:group A of8.90%(17/191), group B4.26%(4/94), that was P>0.05(x2=2.314, P=0.128)when compared A with B. There were no significant differences between groups(P>0.05).
2.2Therapeutic effect on influence of serum markers HBeAg for chronic hepatitis B virus carriers of the two group
(1) The average descent of serum HBeAg before and after treatment
When treating for24weeks, the mean HBeAg was respectively for:group A of1084.84S/Co, group B1072.23S/Co. Among them the comparison with baseline were no statistical difference for group A, P<0.05(P=0.0198), while group B there were no significant differences, P>0.05; There were no significant differences between groups, P>0.05.
When treating for36weeks, the mean HBeAg was respectively for:group A of978.75S/Co, group B1083.43S/Co. Among them the comparison with baseline were statistically significant for group A, P<0.001, while for group B there were no significant differences, P>0.05; There were significant differences between groups when compared, P<0.05(P=0.0249).
When treating for52weeks, the mean HBeAg was respectively for:group A of882.51S/Co, group B1074.32S/Co.Among them the comparison with baseline were statistically significant for group A, P<0.001, while group B there were no significant differences, P>0.05; There were significant differences between groups when compared, P<0.01(P=0.0054).
(2) The negative conversion of serum HBeAg after treatment in each group
When treating for52weeks, the negative conversion of serum HBeAg was respectively for:group A of3.66%(7/191), group B4.26%(4/94), and there were no significant differences between groups when compared, P>0.05.
When treating for52weeks, the HBeAg seroconversion(HBeAg-/HBeAb+) was respectively for:group A of3.66%(7/191), group B3.19%(3/94), and there were no significant differences between groups, P>0.05.
2.3Therapeutic effect on influence of serum markers HBsAg for chronic hepatitis B virus carriers in each group
(1)The average descent of serum HBsAg in the two group after treatment compared to the baseline
When treating for12weeks, compared to the baseline, group A and B declined on average was respectively for:0.146lg,0.094lg,Among them group A was statistically significant when compared, P<0.05(P=0.0407); while group B had no significant differences when compared(P>0.05).
When treating for24weeks, compared to the baseline, group A and B declined on average was respectively for:0.164lg,0.056lg,Among them group A was statistically significant when compared, P<0.05(P=0.0173); while group B had no significant differences when compared (P>0.05).
When treating for36weeks, compared to the baseline, group A and B declined on average was respectively for:0.287lg,0.107lg, Among them group A was statistically significant when compared, P<0.05(P=0.0001); while group B had no significant differences when compared (P>0.05).
When treating for52weeks, compared to the basel ine, group A and B decl ined on average was respectively for:0.428lg,0.140lg,Among them group A was statistically significant when compared, P<0.05(P=0.0001); while group B had no significant differences when compared (P>0.05).
(2)Stratified analyses of the decline extent of serum HBsAg after treatment (HBsAg down>0.5lg,>1lg,>2lg, and the proportion of HBsAg negative conversion),when compared to the baseline
When treating for36weeks, compared to the baseline, the serum HBsAg down>0.5lg was respectively for:group A of14.66%(28/191), group B6.38%(6/94), and there were statistical differences between the two groups, P<0.05(x2=4.1074, P=0.0427); the serum HBsAg down>l lg was respectively for:group A of6.81%(13/191), group B1.06%(1/94), and the comparison between were no statistical difference(P>0.05); the serum HBsAg down>2lg was respectively for:group A of1.05%(2/191), group B0.00%(0/94),and the comparison between were no statistical difference(P>0.05); The proportion of HBsAg negative conversion were respectively for:group A of0.00%(0/191), group B0.00%(0/94), and there were no significant differences between groups (P>0.05).
When treating for52weeks, compared to the baseline, the serum HBsAg down>0.5lg was respectively for:group A of27.23%(52/191), group B8.51%(8/94),and there were statistical differences between the two groups, P<0.01(x2=13.2748, P=0.000269); the serum HBsAg down>1lg was respectively for:group A of10.47%(20/191), group B4.26%(4/94), and the comparison between were no statistical difference(P>0.05); the serum HBsAg down>2lg was respectively for:group A of2.09%(4/191), group B1.06%(1/94),and the comparison between were no statistical difference(P>0.05); The proportion of HBsAg negative conversion were respectively for:group A of0.00%(0/191), group B0.00%(0/94), and there were no significant differences between groups (P>0.05).
2.4Liver histology changes
There were a total of285patients in the two group, and among them26%were patients with active inflammation (≥Grade2) and/or fibrosis (≥stage2) in histology. After treating for52weeks with "Kidney tonifying and detoxification medicinal herbs", there were73cases of patients who did liver biopsy twice, accouting for25.6%of the total.In those patients,there were10cases(13%) whose inflammation of the liver, fibrosis stage, and immunohistochemical HBsAg expression decreased significantly after treatment,3patients with exacerbations, and another60cases not changing significantly.
2.5. Therapeutic effect on influence of the serum immune factors in chronic hepatitis B virus carriers and their relevance with HBV DNA
(1) Therapeutic effect on influence of the serum immune factors in chronic hepatitis B virus carriers
When comparing the baseline cytokines IL-2, IL-4, IL-10, IFN-γ, TNF-a of each group, there were no significant differences between groups, P>0.05.Therefore, the model had good comparability. Changes of each cytokines after treatment showed that:the " Kidney tonifying and detoxification medicinal herbs" could greatly improved the level of IL-2(increased by60.4%and75.7%respectively), IFN-Y level (increased by37.4%and60.1%respectively), and greatly reduced IL-4, IL-10level (42.1%-48.4%). The placebo group almost had no influence on cytokines. In addition to the TNF-a value changes, the testing group's improvement of IL-2, IL-4, IL-10, IFN-γ had significant differences compared to the placedo group, P<0.05. When comparing the the testing group's improvement of IL-2, IL-4, IL-10, IFN-γ and TNF-a, the difference was not statistically significant.And the ratio of "Kidney tonifying and detoxification medicinal herbs" was37.4%.
(2) The decline of serum HBV DNA and its relevance with changes of cytokines of the treatment group
The HBV DNA decline of the treatment group was moderate related with IL-2(Pearson correlation coefficient is-0.417, P<0.01), and weak related with INF-γ (Pearson correlation coefficient is-0.231, P<0.01); The HBV DNA decline of all patients was moderate related with IL-2(Pearson correlation coefficient is-0.425, P<.0.01), and weak related with INF-γ (Pearson correlation coefficient is-0.266, P<0.01). All patients with a more than1lg of HBV DNA down was moderate related with IL-2(Pearson correlation coefficient is-0.428, P<0.01), and very weak related with INF-γ (Pearson correlation coefficient is-0.151, P<0.01).
The IL-2, IFN-y level of the "Kidney tonifying and detoxification medicinal herbs" treatment group with a more than1lg of HBV DNA down was higher than that with a no more than1lg of HBV DNA down, and the differences were statistically significant. When comparing IL-4, IL-10, and TNF-a between groups, the difference was not statistically significant.
Conelus ions
Many studies demonstrate that, for those chronic hepatitis B virus carriers with ALT<1ULT, it still has a risk of disease progression, however there are no specific treatment guidelines. Studying and treating it with "Kidney tonifying and detoxification", the results are as follows.
(1) Among TCM syndrome type distribution rule of the chronic hepatitis B virus carriers, the syndrome of kidney deficiency and spleen deficiency are given priority to. What's more, there are also syndrome of incoordination between liver and stomach, damp-heat obstructing in zhong jiqo, etc.
(2) And the main constitutional type are qi-asthenia constitution and Yang-deficiency constitution as for chronic hepatitis B virus carriers.
(3)"Kidney tonifying and detoxification" inhibits the replication of HBV DNA by rising levels of IL-2&IFN-γ, and reducing levels of IL-4&IL-10. And its anti-hepatitis B virus effect is realized by adjusting the body's immune function,as well as improving the immunologic status.It provides the strong clinical evidence in developing traditional Chinese drugs effectively treating and protecting the chronic hepatitis B virus carriers from the progress of the disease.
引文
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