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만성 B 형 간염 면역 관용기: 치료 할 것인가 말 것인가?
최종기 ( Jonggi Choi ) 대한간학회 2020 Postgraduate Courses (PG) Vol.2020 No.1
Hepatitis B virus (HBV) infection is a major global health issue causing end-stage liver disease or hepatocellular carcinoma. Based on virus-host interactions, natural course of chronic hepatitis B (CHB) infection can be divided into four chronological phases. Immune tolerant (IT) phase, the first phase of natural course of CHB, is defined as normal alanine aminotransferase (ALT) and very high level of HBV DNA according to the current international guidelines and is traditionally considered “benign” disease due to host’s immune tolerance. However, evidences from basic and clinical studies argued that IT phase may not completely be a benign feature. Immunologic studies demonstrated that HBV-specific immune responses in patients with IT phase are as active as those in patients with immune clearance phase, which is indicated for antiviral treatment. In addition, recent large-scale observational studies also support this notion showing that higher and worse long-term clinical outcomes in patients with IT phase than patients with immune active phase under antiviral treatment. Therefore, issues of earlier antiviral treatment and treatment indication expansion beyond current treatment guidelines are currently under hot debate. Nevertheless, opinion deferring treatment for patients with IT phase still prevails given that possibility of spontaneous HBeAg seroclearance, poor response to current treatments in patients with IT phase, and expected good long-term clinical outcomes in patients with genuine IT phase. Evidences from prospective randomized trials warrant to re-determination of treatment indication.