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慢性肝病患者的免疫接种

Author
Raymond S Koff, MD
Section Editor
Sanjiv Chopra, MD, MACP
Deputy Editors
Jennifer Mitty, MD, MPH
Anne C Travis, MD, MSc, FACG, AGAF
Translators
刘敏, 教授

引言

近25年来肝病患者的管理已发生了巨大的改变，使其结局和生存情况得到了改善。肝病的预防也已有了改善；甲型肝炎疫苗和乙型肝炎(hepatitis B, HepB)疫苗也已降低了急性病毒性肝炎的发病率[1]。此外，在美国接种HepB疫苗使慢性乙型肝炎的后遗症减少，尽管还没有特异性丁型肝炎疫苗，接种HepB疫苗也使得丁型肝炎病毒感染显著降低。虽然戊肝疫苗目前还未获美国食品药品监督管理局(Food and Drug Administration, FDA)批准，但在将来有可能可用[2]。这一点很重要，因为在妊娠女性中急性戊肝相关的病死率很高，并且在法国肝脏、肾脏及胰腺移植受者中已有慢性戊型肝炎报道[3]。尽管取得了这些进展，但丙肝疫苗还未研制成功，并且在美国多种病因所致的慢性肝病仍然是一个普遍的健康问题。

从某种意义上讲，慢性肝病患者与一般人群无异。为了维持一般健康状态，两种人群都需要适当的免疫接种。然而，对于部分血源性病原体导致慢性肝病的患者而言，共同的危险因素可能导致乙型肝炎和丙型肝炎双重感染或者暴露于甲型肝炎。数据显示，与一般人群相比，在慢性肝病患者中甲型肝炎病毒感染的检出率更高[4]。此外，对于慢性肝病患者或者肝移植受者，合并另一种急性疾病(肝炎病毒二重感染、流行性感冒和肺炎球菌感染)可能导致比目前没有肝病患者更高的并发症发病率和死亡率。

肝炎病毒、肺炎球菌疾病及流行性感冒感染对于慢性肝病患者的影响将在此讨论。预防性疫苗的效力也将在此讨论。有关这些疫苗的一般安全性和有效性问题的进一步信息，请参见相应专题。

疫苗可预防性感染的影响

针对疫苗可预防的感染(甲型肝炎、乙型肝炎、流行性感冒和肺炎球菌疾病)对于慢性肝病影响的研究，很大程度上被限定在慢性乙型肝炎和丙型肝炎、酒精性肝病、代偿期和失代偿期肝硬化患者及肝移植受者中。

关于急性病毒性甲型肝炎和乙型肝炎、流行性感冒和肺炎球菌感染对其他肝病影响的数据很少。脂肪肝和非酒精性脂肪性肝炎、遗传性血色病、原发性胆汁性肝硬化、自身免疫性肝炎、原发性硬化性胆管炎、α-1抗胰蛋白酶缺乏症、肝豆状核变性、肉芽肿性肝病很少被关注。在一项纳入225例自身免疫性肝病患者的研究中，所有患者接种甲型肝炎疫苗后均获得血清转化，而76%的患者接种乙型肝炎疫苗后达到表面抗原抗体(anti-HBs)血清保护性水平[5]。在对疫苗接种无应答的患者中，免疫抑制治疗和进展期肝病均是常见的情况[5]。其他可能涉及肝脏的系统性疾病(例如，乳糜泻和囊性纤维化)也还未被广泛的研究。尽管如此，一个欧洲专家组推荐，对于囊性纤维化个体，在确诊囊性纤维化时或者发现肝脏受累时接种甲型肝炎病毒(hepatitis A virus, HAV)和乙型肝炎病毒(hepatitis B virus, HBV)疫苗[6]。

                         

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Literature review current through: 2017-06 . | This topic last updated: 2017-04-24.
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