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La infección por virus de la hepatitis B (VHB) representa un importante problema de salud pública en todo el mundo. En las últimas décadas se han producido importantes progresos que han contribuido a una mayor comprensión de la historia natural y las manifestaciones clínicas de esta infección. La fluctuación entre la replicación viral y la respuesta inmunológica del huésped tiene implicaciones en la patogenia y la evolución de la lesión hepática. En el adulto inmunocompetente, la mayor parte de infecciones por VHB se resuelven de forma espontánea, en comparación con una evolución hacia una infección crónica en la mayoría de los recién nacidos. Los pacientes con hepatitis crónica por VHB o hepatitis B crónica pueden presentarse en cuatro fases evolutivas: a) fase de tolerancia inmunológica o inmunotolerancia; b) hepatitis B crónica HBeAg positivo; c) estado de portador inactivo de HBsAg, y d) hepatitis crónica HBeAg negativo. La hepatitis crónica HBeAg positivo o negativo puede evolucionar hacia una cirrosis, una insuficiencia hepática y un carcinoma hepatocelular. Una progresión hacia estas complicaciones es más frecuente en las formas HBeAg negativo, asociadas con mutaciones que afectan a la región pre-core y que mantienen la replicación viral activa. Los factores de riesgo son unos valores altos de ADN-VHB, el aumento de la concentración sérica de transaminasas y algunos genotipos. Estos factores subrayan la necesidad de evaluar y supervisar a todos los portadores del VHB para identificar a los pacientes que pueden beneficiarse de un tratamiento antiviral precoz, evitando de este modo la progresión hasta formas más avanzadas de hepatopatía. Estas medidas pueden contribuir a una mejor prevención y a un tratamiento más eficaz de la hepatitis B.
Palabras clave:
Hepatitis B
Estado de portador crónico de virus de la hepatitis B
Manifestaciones extrahepáticas
Historia natural
Hepatitis B virus (HBV) infection is a serious public health problem worldwide. In the last few decades, major advances have been achieved that have contributed to greater understanding of the natural history and clinical manifestations of this infection. The fluctuation between viral replication and the host's immune response has implications in the pathogenesis and progression of the hepatic lesion. In immunocompetent adults, most HBV infections resolve spontaneously in contrast with progression to chronic infection in most infants. Patients with chronic hepatitis due to HBV or chronic hepatitis B can present at four phases: 1) the immune tolerance phase, 2) HBeAg-positive chronic hepatitis B, 3) inactive HBsAg carrier state, and 4) HBeAg-negative chronic hepatitis. HBeAg-positive or –negative chronic hepatitis can progress to cirrhosis, liver failure and hepatocellular carcinoma.
Progression to these complications is more frequent in HBeAg-negative forms, associated with mutations that affect the pre-core region and maintain active viral replication. Risk factors are HBV-DNA positive serum levels, an increase in serum transaminase levels and some genotypes. These factors highlight the need to evaluate and monitor all HBV carriers to identify those who could benefit from early antiviral treatment, thus avoiding progression to more advanced forms of liver disease. These measures could improve prevention and treatment of hepatitis B.
Key words:
Hepatitis B
Chronic HBV carrier state
Extrahepatic manifestations
Natural history
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