| Severe hepatitis is a kind of acute clinical critical disease caused by a variety of reasons with acute necrosis of massive hepatic cells and severe liver dysfunction so that liver function suddenly reduce or disappear, coagulation disorders, clinical manifestations as hepatic encephalopathy, renal damage and multiple organ failure. In China,90.29%of severe hepatitis is chronic severe hepatitis B (CSHB), with complicated clinical syndromes, variable complications, difficulty in treatment, high mortality rate, poor prognosis, continuous onsets in survivors, and the fatality was reported about60%to80%. In recent years, we have considerable advantage in researches into integrating therapy of Chinese and Western medicine, and make the death rate decline to a certain extent.Previous studies suggested that hepatitis B virus (HBV) genotype and HBV nucleotide mutations may be related to exacerbations of hepatitis B hepatitis, but the relationship between the occurrence of CSHB and HBV mutations in patients with chronic hepatitis B is not clear. The existing research suggested that the mutations in PreS area may be involved in occurrence of CSHB, but also not conclusive.Therefore, we carried out the following studies in this paper. In the clinical research part, clinical efficacy of integrated therapy of Chinese and Western medicine in patients with CSHB was observed. In the experimental research part, the relationship among HBV genotype, gene mutations in PreS area and the occurrence of CSHB was studied.Part one Clinical researchObjective:To observe the clinical efficacy of integrated therapy of Chinese and Western medicine for patients with CSHB.Method:Thirty-six patients with CSHB from the Eighth People’s hospital during March2010to August2011were randomly divided into two groups treated with the integrated therapy of Chinese and Western medicine (treatment group,19cases) or western medicine only (control group,17cases). The main laboratory index, incidence of complications, score of traditional Chinese medical syndromes (TCM score) and clinical efficacy were monitored before and after4weeks treatment. The mortality was observed at the end of the follow-up and the death related factors of CSHB were analyzed.Results:(1) The total bilirubin (TBIL) and prothrombin time activity (PTA) of treatment group were significantly improved after treatment compared with that of the pre-treatment (P<0.05). The treatment group show better effect in reducing TBIL compare with the control group (P<0.05). The alanine aminotransferase (ALT) and albumin (ALB) of both groups were obviously improved after treatment compared with that of the pre-treatment (P<0.01or P<0.05), but there was no significantly difference between groups (P>0.05). The total bile acid (TBA) and cholinesterase (CHE) showed no significant change in both groups before and after treatment (P>0.05).(2) The blood urea nitrogen (BUN) and creatinine (Cr) were in normal range before and after treatment, there was no significant difference within and between groups (P>0.05).(3) Blood ammonia (BLA) showed no significant differences within and between groups before and after treatment.(4) Platelets (PLT) was significantly descended in control group (P<0.01), and the difference was significantly compare with treatment group (P<0.05).(5) After treatment, the negative conversion ratio of HBV DNA in treatment group and control group were10.5%and17.6%, there was no significance variation between groups (P>0.05). The level of HBV DNA was obviously descended, significant difference showed within groups (P<0.01) but not between groups (P>0.05).(6) The incidences of primary peritonitis and fungal infection were significantly lower in treatment group (P<0.05, P=0.09, successively).(7) Compare with pre-post treatment, TCM score descended obviously in treatment group (P<0.01) but not in control group (P>0.05). And significant difference showed between two groups in reducing TCM score (P<0.05).(8) Total effective rate and significant effective rate in treatment group were73.7% and47.4%respectively, and41.2%and11.8%in the control group, after treatment. The comprehensive curative effect and significant efficiency in treatment group were statistically significant over those of control group (P<0.05).(9) At the end of the follow-up, the mortality was21.1%in treatment group, and was41.2%in the control group, the difference between groups showed no significance (P>0.05).(10) Univariate analyses showed that alpha-fetoprotein (AFP), Cr and TCM score contributed statistically to the clinical outcome of patients alive or dead (P<0.01or P<0.05). The death group had higher incidences of all the complications, and in fungal infection, primary peritonitis and hepatic encephalopathy were significantly higher than survival group (P<0.01).Conclusion:(1) Integrating therapy of Chinese and Western medicine apply in treatment of patients with CSHB was beneficial to patients with jaundice faded faster and PLT decline slower. The treatment group had better effect on improving clinical symptoms, relieving TCM scores, decreasing complications, improving clinical efficacy and reducing mortality of patients.(2) Good prognosis in the CSHB patients with higher level of AFP before treatment, while poor prognosis with higher incidence of complications during the treatment. Part two Experimental researchObjective:Explore the relationship among HBV genotypes, gene mutations in PreS area and the occurrence of CSHB. And find the possible CSHB-related mutations.Method:One hundred and twenty HBV infected patients from the Eighth People’s hospital during March2010to August2011were recruited into the present study, including43cases of patients with chronic hepatitis B (CHB),21cases of patients with liver cirrhosis (LC),20cases of patients with hepatocellular carcinoma (HCC), and36cases of patients with CSHB (the same patients in the part one). Totally232serum samples were collected and148serum samples of CSHB patients were collected pre-post treatment and during the follow-up. Nest-PCR was employed for the amplification of the HBV genotype and PreS gene, and PCR product of PreS gene was sequenced. Then the relationship among HBV genotypes, gene mutations of PreS area and the occurrence of CSHB was analyzed.Results:(1) Research of HBV genotype1) The distribution of HBV genotype in CHB group, LC group, HCC group and CSHB group was significant different (P<0.05). The major HBV genotypes in CHB group and CSHB group were genotype B, and genotype C appeared primarily in LC and HCC groups. The distribution of HBV genotypes in CSHB showed significant difference with LC group and HCC group (P<0.01).2) In CHB group, there were no significant differences in clinical materials of genotype B and genotype C (P>0.05). In LC group, the level of HBV DNA and platelets (PLT) in genotype C were obviously higher than genotype B (P<0.01, P=0.071, successively). In HCC groups, the level of PLT and Cr displayed significantly difference between genotype B and genotype C. In CSHB group, the HBeAg rate was higher and TBA, ALT, ALB, CHE were lower in genotype C (P values in the order:0.071,0.064,0.055and0.093, compare with genotype B).3) The clinical stages, mortality and clinical effective in CSHB group showed no significant difference between genotype B and genotype C.4) Longitudinal analysis of genotypes in CSHB group showed that genotype in two cases of nine patients with clinical cure changed from B to B/C then last to C.(2) Research of gene mutation in HBV PreS area1) Spot-mutations were found in61of62amplified gene segments of PreS area. Five more mutation sites were A2873(93.5%), T3041(91.9%), G3150(93.5%), A46(93.5%) and A49(64.5%). The mutations of PreS area from most to least was HCC group, CSHB group, LC group and CHB group, the difference being significant (P<0.01). All significant difference was detected between two groups (P<0.01) except between LC group and CSHB group (.P>0.05).2) Compared CSHB and CHB group mutation showed A2875, C2901, C2910, C2922, A2951, G2962, A2964, C2980, G2988, G3006, G3021, C3057, T3060, G3063, A3066, G3069, C3097, G3102, T3108, G3156, T3169, A3171, G3186, C3191, A20, T25, A27, C40, A76, G85, G87, C93, A96, A99, T105, G110, A127, A132, T147together39units place mutation had the significance (P<0.01or P<0.05), all OR>1.3) Compared CSHB and LC group mutation showed A2946and C3009had the significance (P<0.05), all OR<1.4) Compared CSHB and HCC group mutation showed C3009and G3156had the significance (P<0.05), all OR<1.5) The initiation codon deletion and mutation of PreS1and PreS2were2cases (8.3%) and8cases (33.3%) in CSHB group,1case (4.2%) and1case (4.2%) in CHB group,0case and2cases (20%) in LC group, and0case and3cases (75%) in HCC group. Compared with CHB group, the deletion and mutation rate of PreS2was significant higher in CSHB group (P<0.05) and HCC group (P<0.01), all OR>1.6) There did not show any significant difference in PreS gene mutation between death group and survival group (P>0.05).7) Longitudinal analysis of PreS gene mutation in CSHB group showed that the number of mutations obviously changed in three patients before and after treatment. The numbers changed from11(0week) to70(4week), from10(0week) to64(4week) then last to9(24week), and from69(0week) to11(12week) in patient of CSHB-6, CSHB-9and CSHB-15, successively.Conclusion:(1) In CSHB patients, genotype B appeared primarily, clinical situation, clinical efficacy, and clinical outcome were similar between genotype B and genotype C.(2) During the treatment, two cases of nine CSHB patients with clinical cure changed from B to B/C then to C, and this change did not worsen the situation.(3) Gene mutation of PreS area was possibly related to the occurrence of CSHB and which was significant higher than that in CHB group.(4) Gene mutations of PreS area changed dynamically in patients with CSHB during the treatment. It appeared more in progression stage, but along with the condition improved, its number decline. |
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