Reading guide in this issue
Li Yufang: Pay attention to kidney injury in middle-aged and elderly patients with hepatitis B cirrhosis
Expert Profile
/Prof. Li Yufang/
●Professor, master's supervisor
●Chief physician of the General Hospital of Ningxia Medical University
●Director of the Department of Infectious Diseases, School of Clinical Medicine, Ningxia Medical University
●Member of the Hepatology Society of the Chinese Medical Association
●Member of the Liver Failure and Artificial Liver Group of the Society of Infectious Diseases of the Chinese Medical Association
●Member of the Infection Branch of the Chinese Preventive Medicine Association
●Member of the Critical and Critical Care Society of the Chinese Association of Integrative Medicine
●Member of the Liver Disease Professional Committee of the Chinese Association of Integrative Medicine
●Chairman of the Ningxia Alliance of Asia-Pacific Alliance for Diagnosis and Treatment of Liver Diseases (APALD).
●Member of the National Collaborative Group for Difficult and Severe Liver Diseases
●Chairman of Ningxia Hepatology Society
●Vice Chairman of Ningxia Society of Infectious Diseases
●Director of the Zhongxia Society of Medical Sciences
●Member of the editorial board of "GUT Chinese Edition of Liver Disease", "Chinese Journal of Hepatology", "Journal of Clinical Hepatobiliary Diseases", "Journal of Practical Hepatology", "Journal of Liver Diseases of Integrated Traditional Chinese and Western Medicine" and other journals
Q: What are the main populations of hepatitis B? What is the condition?
Hepatitis B virus (HBV) infection is endemic worldwide, with the WHO reporting that the global prevalence of HBsAg in the general population was 3.8% in 2019, with 296 million chronically infected people. The 2019 epidemiological survey estimated that the prevalence of HBsAg in the general population in mainland China was 5%~6%, and there were about 70 million cases of chronic HBV infection, including about 20 million ~ 3,000 cases of chronic hepatitis B virus. Therefore, the prevalence of HBV in mainland China is still relatively high, and HBV infection has not only caused a huge economic and health burden to the mainland and the world.
Since the mainland included hepatitis B vaccine in the national immunization program in 2002 and began to implement the neonatal HepB immunization policy, the hepatitis B infection rate has decreased significantly compared with before. A 2006 national hepatitis B serological epidemiological survey showed that the prevalence of HBsAg in people aged 1~59 was 7.18%, and the prevalence of HBsAg in children under 5 years old was 0.96%, which had been reduced to <1%, but the HBsAg carrier rate in people aged 15~59 years was 8.57%, and the survey showed that the degree of HepB vaccination in people aged 1559 was generally low (HepB vaccination rate was <10%), and they were susceptible to HBV infection. In 2014, the results of the national hepatitis B seroepidemiological survey of people aged 1~29 years showed that the prevalence of HBsAg in people aged 1~4, 5~14 and 15~29 years were 0.32%, 0.94% and 4.38%, respectively. The trend of HBV infection incidence in mainland China from 2006 to 2014 also showed that the HBV infection rate in the age group under 29 years old decreased significantly, and the HBV infection rate in the age group over 55 years old showed a significant increase trend.
We all know that China is currently facing the problem of population aging, and the middle-aged and elderly people in the mainland have become the main group of hepatitis B infection, which has also been confirmed by the outpatient survey of liver disease in our hospital, and the incidence of hepatitis B cirrhosis is relatively high among the middle-aged and elderly people.
Q: What kind of symptomatic treatment is needed for these patients? What do I need to pay attention to during the treatment?
According to the latest 2022 guidelines for the prevention and treatment of chronic hepatitis B, hepatitis B patients with cirrhosis decompensation require anti-hepatitis B virus therapy as long as the surface antigen is positive; For compensated patients, anti-HBV therapy is also required as long as HBV DNA is positive. Therefore, antiviral therapy is essential. However, some antiviral drugs can cause damage to the kidneys. Therefore, while treating hepatitis B cirrhosis, we also need to protect the patient's kidneys, so it is very important to choose the right medication.
Studies have reported a decrease in eGFR with age. After the age of 40, the eGFR decreased by nearly 10 ml/min for every 10 years of age. At age 80, the average eGFR is almost half that of young adults. Middle-aged and elderly people often develop hypertension, diabetes, and metabolic syndrome, which are all risk factors related to chronic kidney disease, and the use of corresponding therapeutic drugs for concomitant diseases will also lead to impaired kidney function as an excretory organ of drugs. Our study showed that patients with hepatitis B cirrhosis had a higher incidence of kidney failure compared to patients with chronic hepatitis B; Middle-aged and older adults also have a higher incidence of kidney damage than younger adults, which are risk factors for kidney damage.
In addition, renal impairment in patients with hepatitis B cirrhosis is not only age-related, but also associated with hepatitis B infection. Hepatitis B not only affects liver cell damage, but it can also affect kidney function. For example, hepatitis B-associated nephritis, hepatorenal syndrome due to cirrhosis, and renal tubular acidosis due to cirrhosis are all diseases that are closely related to liver disease and kidney disease. In traditional Chinese medicine, there is also a saying that the liver and kidney are homologous, which refers to the close relationship between the liver and the kidneys, and long-term illness can hurt the kidneys. When the disease progresses to a certain extent, many diseases will cause damage to kidney function, so it is necessary to pay attention to the patient's kidney damage during the treatment of hepatitis B cirrhosis.
Q: Will there be damage to the kidneys in the choice of medication?
For middle-aged and elderly patients with hepatitis B cirrhosis, when choosing anti-hepatitis B virus therapy, we should choose drugs that are less harmful to the kidneys. At present, the guidelines recommend three strong and low-resistance anti-hepatitis B virus drugs, namely entecavir, disofo fumarate tenofovir, and tenofovir alafenol fumarate. Among them, a large number of studies have reported that tenofovir, dipyrofolate fumarate, does cause damage to the kidneys.
However, because hepatitis B requires long-term medication, can other drugs cause damage to the kidneys?
We compared renal function in patients who had been on entecavir for more than 10 years with those who had been on entecavir for less than 10 years and found a significant difference between the two. This shows that although entecavir is less damaging to the kidneys, long-term use can still lead to kidney damage.
In addition, for entecavir, we are also faced with a problem, that is, lamivudine and entecavir have the same resistance site, if lamivudine has been used before and drug resistance develops, and then entecavir, the drug resistance rate will be significantly increased. Therefore, in the presence of a very high risk of resistance, the first choice of antiviral therapy with entecavir is not an optimal option. For patients who have been on entecavir for more than 10 years, we suggest that switching to drugs with less renal impairment should be considered to reduce the risk of renal impairment with long-term treatment.
In short, when treating middle-aged and elderly patients with hepatitis B cirrhosis, we must consider the patient as a whole, rather than simply focusing on the therapeutic effect of HBV DNA. When treating liver disease, we must avoid the damage caused by drugs to other organs in order to improve the overall health and quality of life of patients.