血液透析人群中消除丙型肝炎病毒感染

摘要: 我国血液透析人群呈逐年增长的趋势。由于血液透析治疗的特殊性，血液透析患者的丙型肝炎病毒（HCV）感染的患病率和新发病率都远高于普通人群。为了实现世界卫生组织2030年消除丙型肝炎公共卫生危害的倡议，实现血液透析人群的微消除，应严格执行标准预防，做好手卫生，切断医源性感染的途径，特别是避免血液透析中心的HCV感染暴发；对新入和转换透析中心的患者进行HCV感染筛查，对维持性血液透析患者定期筛查，及早发现HCV新发感染；与专科医生合作，对有HCV感染的血液透析患者进行直接抗病毒药物治疗。
- 肾透析 /
- 肝炎病毒属 /
- 疾病消除
Abstract: The hemodialysis population is increasing year by year in China. Due to the specific nature of hemodialysis treatment， the prevalence and incidence rates of hepatitis C virus （HCV） infection in hemodialysis patients are much higher than the general population. In order to achieve the WHO’s initiative to eliminate HCV by 2030 and realize the micro-elimination of HCV in the hemodialysis population， standard infection control and hand hygiene procedures should be implemented to cut off the route of iatrogenic infection， especially to prevent the outbreak of HCV infection in hemodialysis centers. Screening for HCV infection should be conducted for patients newly admitted to the hemodialysis center or transferred to another hemodialysis center， and regular screening should be conducted for patients receiving maintenance hemodialysis to identify new HCV infections in the early stage. It is also necessary to collaborate with specialists and provide direct-acting antiviral therapy for hemodialysis patients with HCV infection.
- Renal Dialysis /
- Hepacivirus /
- Disease Eradication

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表 1 血液透析中心与HCV传播相关的常见感染控制问题^［14］

Table 1. Common infection control issues related to HCV transmission in hemodialysis centers^［14］

感染控制问题
在污染环境（包括患者治疗区）准备注射用药将单剂药物瓶重复用于多例患者使用移动车向患者运送用品或药物患者间共用的环境表面未充分清洁或消毒未隔开清洁区域与污染区域在不同操作或患者间未更换手套或进行手卫生交接过程匆忙员工与患者的比例低

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表 2 与预防HCV传播相关的标准预防措施^［14］

Table 2. Standard precautions related to preventing HCV transmission^［14］

标准预防措施
适当的手卫生和更换手套，特别是在接触不同的患者间、进行侵入性操作前以及接触血液和潜在的血液污染表面/用品后
采用无菌技术在适当的清洁区域准备静脉用药，并进行正确的静脉用药管理
对透析机表面进行彻底的清洁和消毒，特别是高接触表面
将干净用品与受污染的材料和设备充分分开

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表 3 血液透析患者丙型肝炎监测及诊治一览表^［15］

Table 3. List of monitoring， diagnosis and treatment of hepatitis C in hemodialysis patients^［15］

项目	丙型肝炎
监测频率	1.新导入或新转入患者即时检测，3个月内复检 2.长期透析患者每6个月1次 3.阳性转阴性患者前6个月每月1次，后6个月每3个月1次 4.新发患者的密切接触者即时检测，3个月内复检 5.不能解释转氨酶异常升高应检测HCV RNA，建议有条件单位检测HCV抗原
治疗区域安排	1.隔离透析治疗区专机血液透析 2.居家透析治疗
进入隔离透析区治疗条件	HCV RNA阳性或检测HCV抗原时，HCV抗原阳性
解除隔离透析区治疗条件	HCV RNA阴性或检测HCV抗原时，HCV抗原阴性
解除隔离透析治疗方案	1.首次转阴之日起6个月继续在隔离治疗区血液透析 2.持续阴性6个月以上患者，可于非隔离区进行血液透析
血液透析器/滤器/透析管路复用	不能
新发传染病上报	24 h内

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表 4 透析人群中具有有效证据的DAA列表^［14］

Table 4. Direct-acting antiviral （DAA） regimens with evidence of effectiveness for hemodialysis populations^［14］

DAA	HCV基因型	证据质量（总例数）
Sofosbuvir/Velpatasvir，索磷布韦/维帕他韦（丙通沙），12周	泛基因型	高（405）
Glecaprevir/Pibrentasvir，格卡瑞韦/哌仑他韦（艾诺全），8周	泛基因型	中（529）
Sofosbuvir/Daclatasvir，索磷布韦/达拉他韦，12或24周	泛基因型	中（278）
Sofosbuvir/Ledipasvir，索磷布韦/雷迪帕韦（夏帆宁），12周	泛基因型	中（220）
Grazoprevir/Elbasvir，格拉瑞韦/艾尔巴韦（择必达），12周	1a，1b，4	中（962）
PrO±D，奥比帕利/达塞布韦（维建乐/易奇瑞），12周	1a，1b，4	中（582）
Daclatasvir/Asunaprevir，达拉他韦/阿舒瑞韦（百立泽/速维普），24周	1b	低（341）

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