{"id":26026,"date":"2022-12-26T10:00:17","date_gmt":"2022-12-26T07:00:17","guid":{"rendered":"https:\/\/www.klimikdergisi.org\/?p=26026"},"modified":"2023-01-13T11:21:37","modified_gmt":"2023-01-13T08:21:37","slug":"hepatit-b-virusu-dna-alevlenmesi","status":"publish","type":"post","link":"https:\/\/www.klimikdergisi.org\/tr\/2022\/12\/26\/hepatit-b-virusu-dna-alevlenmesi\/","title":{"rendered":"In Vitro<\/i> Fertilizasyon S\u0131ras\u0131nda Hepatit B Virusu DNA Alevlenmesi"},"content":{"rendered":"

G\u0130R\u0130\u015e<\/h2>\n

Kronik hepatit B, siroz ve karaci\u011fer kanserine yol a\u00e7abilen k\u00fcresel bir sa\u011fl\u0131k sorunudur. D\u00fcnya genelinde yakla\u015f\u0131k 400 milyon ki\u015finin kronik hepatit B hastas\u0131 oldu\u011fu tahmin edilmektedir (1). D\u00fcnya Sa\u011fl\u0131k \u00d6rg\u00fct\u00fc\u2019n\u00fcn hepatit B s\u00fcrveyans\u0131na g\u00f6re \u00fclkemiz %2-8 oran\u0131yla orta endemik b\u00f6lgeler aras\u0131ndad\u0131r (2).<\/p>\n

G\u00fcn\u00fcm\u00fczde, kronik hepatit B tedavisinde daha potent ve daha az yan etkili ila\u00e7lar kullan\u0131lmaktad\u0131r. En ideal tedavi sonlan\u0131m noktas\u0131 hepatit B y\u00fczey antijeni (HBsAg) kayb\u0131 ve anti-HBs serokonversiyonu olmakla birlikte kabul edilebilir sonlan\u0131m viral y\u00fck\u00fc bask\u0131lamakt\u0131r (3). B\u00f6ylece hepatit B\u2019nin neden oldu\u011fu siroz, karaci\u011fer yetmezli\u011fi ve karaci\u011fer kanseri gibi komplikasyonlar \u00f6nlenebilir.<\/p>\n

Hepatit B, hepatotropik bir virus olsa da ekstrahepatik bir\u00e7ok dokudan izole edilmi\u015ftir. Pankreas, b\u00f6brek, deri, periferik kan monon\u00fckleer h\u00fccreleri, lenf nodlar\u0131, dalak, kemik ili\u011fi, kolon, mide, testis ve overde HBsAg saptanm\u0131\u015ft\u0131r (4, 5). \u00d6zellikle over dokusunda saptanmas\u0131 vertikal ge\u00e7i\u015f i\u00e7in risk olu\u015fturmaktad\u0131r (6). \u0130nfertilite ile ba\u015fvuran \u00e7iftlere bu nedenle in vitro<\/i> fertilizasyon (IVF) \u00f6ncesinde hepatit B seroloji taramas\u0131 yap\u0131lmaktad\u0131r.<\/p>\n

Bu olgu sunumunda; HBeAg pozitif kronik hepatit B nedeniyle antiviral tedavi ba\u015flanan ve hepatit B virusu (HBV) viral y\u00fck\u00fc bask\u0131lanan ancak IVF tedavisi s\u0131ras\u0131nda viral alevlenme g\u00f6zlenen bir hasta sunuldu.<\/p>\n

OLGU<\/h2>\n
\"\"

\u015eekil 1.<\/strong> HBV DNA, ALT ve AST D\u00fczeylerinin Seyri<\/p><\/div>\n

Otuz sekiz ya\u015f\u0131nda kad\u0131n hasta 2016 y\u0131l\u0131nda kronik hepatit B tan\u0131s\u0131 ald\u0131. Serolojik olarak HBsAg, anti-HBc IgG, HBeAg de\u011ferleri pozitif iken anti-HBs ve anti-HBe de\u011feri negatif idi. Tedavinin ba\u015flang\u0131c\u0131nda bak\u0131lan karaci\u011fer fonksiyon testlerinde; alanin aminotransferaz (ALT) 46 U\/ml ve aspartat aminotransferaz (AST) 67 U\/ml olarak saptand\u0131. Karaci\u011fer fonksiyon testlerinde hafif y\u00fckseklik ve aile \u00f6yk\u00fcs\u00fc olmas\u0131 nedeniyle yap\u0131lan karaci\u011fer biyopsisinde; histolojik aktivite indeksi (HA\u0130) 8 ve fibrosis-4 (F\u0130B-4) skoru 3 olarak sonu\u00e7land\u0131. Hastaya tenofovir disoproksil fumarat tedavisi ba\u015fland\u0131. \u0130ki ay sonra HBV DNA d\u00fczeyi bask\u0131land\u0131 ve karaci\u011fer fonksiyon testleri normal s\u0131n\u0131rlara geldi. Ayn\u0131 tedaviye devam eden hastan\u0131n kontrollerinde HBV DNA negatif iken 2020 y\u0131l\u0131nda 630 000 000 IU\/ml saptanmas\u0131 \u00fczerine istenen HBV ila\u00e7 diren\u00e7 analizinde ila\u00e7 gruplar\u0131na diren\u00e7 saptanmad\u0131. Anti-HCV, anti-HIV, anti-HDV IgM ve IgG, anti-HAV IgM ve HDV RNA negatif saptand\u0131. Hasta tedaviye uyumlu olup kontrollerine d\u00fczenli gelmekteydi. Tenofovir disoproksil fumarat tedavisi kesilerek entekavir ba\u015fland\u0131. \u00c7ekilen bat\u0131n manyetik rezonans (MR) sonucunda herhangi bir patoloji saptanmad\u0131. Malignite olas\u0131l\u0131\u011f\u0131n\u0131 d\u0131\u015flamak i\u00e7in \u00e7ekilen pozitron emisyon tomografisi de normaldi. Ancak entekavirin,\u00a0 <\/span>HBV DNA d\u00fczeyini bask\u0131layamamas\u0131 nedeniyle tedaviye tenofovir alafenamid eklendi. Hastan\u0131n karaci\u011fer fonksiyon testleri ve HBV DNA d\u00fczeyinin zaman i\u00e7indeki seyri \u015eekil 1\u2019de g\u00f6sterildi.\u00a0<\/span><\/p>\n

\u0130ki kere daha HBV ila\u00e7 diren\u00e7 analizi yap\u0131ld\u0131 ancak diren\u00e7 saptanmad\u0131. Hastan\u0131n \u00f6yk\u00fcs\u00fc derinle\u015ftirildi\u011finde, Haziran 2019\u2019da IVF tedavisi i\u00e7in; koriogonadotropin alfa, follitropin alfa, setroreliks ve triptorelin asetat hormon preparatlar\u0131 ald\u0131\u011f\u0131 \u00f6\u011frenildi.<\/p>\n

\u0130RDELEME<\/h2>\n

\u00dclkemizde hepatit B seroprevalans\u0131n\u0131n %2-8 oldu\u011fu g\u00f6z \u00f6n\u00fcne al\u0131nd\u0131\u011f\u0131nda infertilite i\u00e7in ba\u015fvuran \u00e7iftlerde de hepatit B\u2019ye s\u0131k\u00e7a rastlanmaktad\u0131r (7). Hepatit B serolojisini; IVF tedavisi \u00f6ncesi taramak hem maternal ge\u00e7i\u015fi engellemek hem de oositleri ayr\u0131 yerlerde saklay\u0131p \u00e7apraz bula\u015fmay\u0131 \u00f6nlemek a\u00e7\u0131s\u0131ndan \u00f6nem arz etmektedir. Maternal ge\u00e7i\u015fi engellemek i\u00e7in kronik hepatit B ta\u015f\u0131y\u0131c\u0131lar\u0131nda, viral y\u00fck\u00fc bask\u0131layarak hamilelik planlamak \u00f6nemlidir. Ancak \u00fclkemizde, Sosyal G\u00fcvenlik Kurumu Sa\u011fl\u0131k Uygulama Tebli\u011fi\u2019ne g\u00f6re antiviral tedavi uygulanabilmesi i\u00e7in hastalar\u0131n HBV viral y\u00fck\u00fc >2000 ve\/veya HA\u0130 \u22656, fibrozis\u22652 olmal\u0131d\u0131r (8). Bu nedenle \u00e7o\u011fu hepatit B ta\u015f\u0131y\u0131c\u0131s\u0131 antiviral tedavi almadan t\u00fcp bebek i\u015flemlerine ba\u015flamaktad\u0131r.\u00a0<\/span><\/p>\n

\u00d6te yandan her ne kadar virus y\u00fck\u00fc bask\u0131lansa da IVF tedavisi s\u0131ras\u0131nda olan over stim\u00fclasyonunda viral replikasyonun artmas\u0131 muhtemeldir (9). Bu da vertikal ge\u00e7i\u015fi art\u0131rabilecek di\u011fer bir nedendir. Mak ve arkada\u015flar\u0131 (10), 64 hepatit B ta\u015f\u0131y\u0131c\u0131s\u0131 kad\u0131nda, oosit al\u0131m\u0131 s\u0131ras\u0131nda aspire edilen folik\u00fcler s\u0131v\u0131da HBV DNA\u2019y\u0131 \u00f6l\u00e7m\u00fc\u015f ve bunun serum HBV DNA d\u00fczeyi ile korele oldu\u011funu g\u00f6stermi\u015ftir. Ayn\u0131 \u015fekilde Hu ve arkada\u015flar\u0131n\u0131n (11) \u00e7al\u0131\u015fmas\u0131nda da, serum HBV DNA d\u00fczeyleri ile korele olarak over dokusunda HBV replikasyonu oldu\u011fu bildirilmi\u015ftir. S\u00f6z konusu \u00e7al\u0131\u015fmada, serum HBV DNA \u2265106 <\/sup>kopya\/ml ise oositlerin %17\u2019sinde, serum HBV DNA <106<\/sup> kopya\/ml ise oositlerin %5.4 \u00fcnde HBV DNA pozitif saptanm\u0131\u015ft\u0131r.\u00a0 <\/span>Her ne kadar do\u011fumda hepatit B a\u015f\u0131s\u0131 ve imm\u00fcnglobulin uygulansa da %3 oran\u0131nda vertikal ge\u00e7i\u015f i\u00e7in rezid\u00fcel risk bulunmaktad\u0131r; hepatit B do\u011fumda al\u0131nd\u0131\u011f\u0131nda kronikle\u015fme oran\u0131 da artmaktad\u0131r (12).\u00a0<\/span><\/p>\n

Olgumuzda \u00fc\u00e7 kere diren\u00e7 testi yap\u0131lm\u0131\u015f olup herhangi bir antiviral ajana diren\u00e7 saptanmad\u0131. Tedavisini d\u00fczenli olarak takip eden hastada, koinfeksiyon veya e\u015flik eden malignite olas\u0131l\u0131\u011f\u0131 da d\u0131\u015fland\u0131. Bu durumda t\u0131pk\u0131 over folik\u00fcl s\u0131v\u0131s\u0131nda oldu\u011fu gibi serumda da viral replikasyonun verilen stim\u00fclan hormonlar nedeniyle artt\u0131\u011f\u0131 d\u00fc\u015f\u00fcn\u00fclebilir.\u00a0<\/span><\/p>\n

Sonu\u00e7 olarak; kronik hepatit B hastalar\u0131nda halk sa\u011fl\u0131\u011f\u0131 a\u00e7\u0131s\u0131ndan, viral y\u00fck\u00fc \u00f6zellikle do\u011furganl\u0131k \u00e7a\u011f\u0131nda ve infertilite tedavisi s\u0131ras\u0131nda yak\u0131ndan takip etmek \u00f6nemlidir.<\/p>\n","protected":false},"excerpt":{"rendered":"

G\u0130R\u0130\u015e Kronik hepatit B, siroz ve karaci\u011fer kanserine yol a\u00e7abilen k\u00fcresel bir sa\u011fl\u0131k sorunudur. D\u00fcnya genelinde yakla\u015f\u0131k 400 milyon ki\u015finin kronik hepatit B hastas\u0131 oldu\u011fu tahmin edilmektedir (1). D\u00fcnya Sa\u011fl\u0131k \u00d6rg\u00fct\u00fc\u2019n\u00fcn hepatit B s\u00fcrveyans\u0131na g\u00f6re \u00fclkemiz %2-8 oran\u0131yla orta endemik b\u00f6lgeler aras\u0131ndad\u0131r (2). G\u00fcn\u00fcm\u00fczde, kronik hepatit B tedavisinde daha potent ve daha az yan etkili […]<\/p>\n","protected":false},"author":4,"featured_media":26257,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[5131],"tags":[5616,5617,3328],"class_list":["post-26026","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-olgu-sunumu","tag-hbv-alevlenmesi","tag-ivf","tag-kronik-hepatit-b"],"acf":[],"_links":{"self":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/26026","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/users\/4"}],"replies":[{"embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/comments?post=26026"}],"version-history":[{"count":5,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/26026\/revisions"}],"predecessor-version":[{"id":26326,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/26026\/revisions\/26326"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/media\/26257"}],"wp:attachment":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/media?parent=26026"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/categories?post=26026"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/tags?post=26026"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}