Documente Academic
Documente Profesional
Documente Cultură
Section Editors
Richard J Glassock, MD,
MACP
Martin S Hirsch, MD
Deputy Editor
John P Forman, MD,
MSc
All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Jan 2016. | This topic last updated: Jan 11, 2016.
INTRODUCTION Infection with hepatitis B virus (HBV) may be associated with a variety of
renal diseases [1,2]. The three most common types of renal disease resulting from HBV
infection are:
Membranous glomerulonephritis
Membranoproliferative glomerulonephritis (MPGN)
Polyarteritis nodosa (PAN)
Introducere Infecia cu virus hepatic B (VHB) poate fi asociat cu o varietate de boli renale. Cele 3
mai frecvente tipuri de boli renale ce rezult n urma infeciei cu VHB sunt:
Glomerulonefrita membranoas
Glomerulonefrita membranoproliferativa (MPGN)
Poliarterita nodoas (PAN)
n plus, infecia cu VHB a fost asociat cu glomerulonefrita proliferativ mezangial, nefropatie cu IgA, i
amiloidoza.
Acest subiect ofer o privire de ansamblu asupra tipurilor de boli renale asociate infeciei cu VHB, precum
si diagnosticului i managementului unor astfel de pacieni. Atunci cnd este necesar, cititorul este
direcionat spre discuii mai detaliate privind manifestrile clinice i diagnosticul bolilor renale specifice i
diagnosticul serologic al hepatitei B. Discuiile complete n legtur cu infecia cu virus hepatitic B, la
pacienii tratai cu hemodializ i la pacienii cu transplant de rinichi sunt prezentate n alt parte. (See
"Hepatitis B virus and dialysis patients" and "Hepatitis B virus infection in renal transplant recipients".)
EPIDEMIOLOGIE I PATOGENEZ
Epidemiologie - Boli renale asociate infeciei cu virusul hepatic B (VHB) apar cel mai frecvent n zonele
endemice, n special atunci cand infecia survine n timpul perioadei natale i copilariei, ceea ce crete
probabilitatea de a deveni un purttor cronic [3]. Prin comparaie, frecvena bolii renale asociate VHB
este sczut n Statele Unite i n Europa de Vest, datorit prevalenei mai mici a infeciei cronice cu
VHB n general, i o probabilitate mai mic de infectie n perioada copilriei [3]. (See "Epidemiology,
transmission, and prevention of hepatitis B virus infection", section on 'Epidemiology of chronic HBV' and
"Overview of hepatitis B virus infection in children and adolescents".)
The widespread use of hepatitis B vaccination has decreased the incidence of HBV-related renal diseases,
providing evidence of the probable pathogenetic role of HBV [4,5]. (See "Hepatitis B virus vaccination".)
Pathogenesis Although some affected patients have a history of active hepatitis, a large proportion of patients
have only mild to moderate elevations in serum aminotransferases. These patients are positive for hepatitis B
surface antigen (HBsAg) and hepatitis B core antibody (anti-HBc), and, in patients with membranous nephropathy,
hepatitis B e antigen (HBeAg). The relationship between HBV variants (eg, precore and core promoter mutations)
that prevent or decrease HBeAg production (despite active viral replication by DNA testing) and renal disease has
not been well described. (See "Clinical significance and molecular characteristics of common hepatitis B virus
variants", section on 'Precore and core promoter variants' .)
Utilizarea pe scar larg a vaccinului mpotriva virsului hepatitei B a sczut inciden a bolilor renale asociate cu VHB,
furniznd dovezi ale rolului patogenetic probabil al VHB [4,5]. (See "Hepatitis B virus vaccination".)
Patogenez - Cu toate c unii pacieni afectati au antecedente de hepatit activ, o propor ie mare de pacien i au
doar creteri uoare pn la moderate ale transaminazelor serice. Ace ti pacien i sunt pozitivi pentru antigenul de
suprafa al hepatitei B (AgHBs) i anticorpul de baz al hepatitei B (anti-HBc), iar pacien ii cu nefropatie
membranoasa, sunt pozitivi pentru antigenul e al hepatitei B (AgHBe). Rela ia dintre variantele VHB (de
exemplu???????) care previn sau reduc producia de AgHBe (n ciuda replicrii viral active prin testarea ADN-ului)
i boala renal nu a fost bine descris. (See "Clinical significance and molecular characteristics of common hepatitis
B virus variants", section on 'Precore and core promoter variants' .)
Rolul patogenetic al infeciei cu VHB a fost documentat n principal prin demonstrarea complexelor
antigen-anticorp ale hepatitei B n leziunile renale prin microscopie cu imunofluorescen, inclusiv
depunerea de AgHBe n nefropatia membranoasa [1,6,7]. ADN VHB i ARN VHB au fost identificai n
celulele glomerulare i tubulare la pacienii afectati; Cu toate acestea, rolul acestor acizi nucleici virali n
dezvoltarea leziunii renale rmne s fie confirmat [8,9]. Datele preliminare sugereaz c VHB purificat
poate induce proliferarea celular glomerular mezangial uman i exprimarea colagenul de tip IV [10].
TIPURI DE BOLI RENALE - Boli renale asociate cel mai frecvent infec iei cu virusul hepatitei B (VHB) includ
nefropatia membranoas, glomerulonefrita membranoproliferativ (MPGN) i poliarterita nodoas (PAN) [ 1,2,6].
Manifestrile clinice ale acestor trei boli sunt discutate n detaliu n alt parte. (See "Causes and diagnosis of
DIAGNOSTIC - Biopsia renal este necesar pentru a confirma prezena unui proces glomerular
de baz, cu toate c o recoltare diferit dintr-un alt loc din esut poate fi necesar pentru a confirma
poliarterita nodoas (PAN). (See "Clinical manifestations and diagnosis of polyarteritis nodosa in
adults", section on 'Biopsy'.)
Confirming the etiologic role of hepatitis B virus (HBV) in any of these disorders may, at times, be difficult
since the detection of viral antigen deposition in the kidney requires techniques that may not be available
in the routine clinical setting. In addition, the presence of viral antigens in the renal tissue may be
coincidental rather than indicative of a causal relationship [6]. However, a presumptive diagnosis may be
made in patients whose biopsy findings are consistent with an HBV-associated renal disease and when
the patient is a child from an HBV-endemic area or an adult whose serologic tests show circulating
hepatitis B surface antigen (HBsAg) and hepatitis B e antigen (HBeAg) [1,2].
Confirmarea rolului etiologic al virusului hepatic B (VHB) n oricare dintre aceste tulburri poate fi uneori
dificil, deoarece detectarea depunerii de antigen viral n rinichi necesit tehnici care s nu fie disponibile n
cadrul clinic obinuit. n plus, prezena antigenilor virali n esutul renal poate fi mai degrab o coinciden,
dect un indiciu spre o relaie cauzal [6]. Cu toate acestea, un diagnostic prezumtiv poate fi fcut la
pacienii ale cror rezultate bioptice sunt in concordanta cu boli renale asociate cu VHB i atunci cnd
pacientul este un copil dintr-o zon endemic cu VHB sau un adult ale crui teste serologice arat antigen
de suprafa al hepatitei B circulant (AgHBs) i antigen e hepatic B (AgHBe) [1,2].