Hepatitis B virus-associated glomerulonephritis

　　Hepatitis B virus (HBV) associated glomerulonephritis mainly manifests as membranous nephropathy and membranous proliferative glomerulonephritis. It is generally believed that membranous nephropathy is caused by the initial implantation of the small molecular HBe antigen under the subendothelial layer of the glomerular capillary loop, followed by the binding of the positively charged anti-HBe antibody to the pre-implanted HBe antigen under the subendothelial layer, resulting in an in situ immune complex glomerulonephritis. Membranous proliferative glomerulonephritis is caused by the deposition of macromolecular surface antigens (HBsAg) and their immune complexes under the subendothelial layer of the glomerular capillary loop through the mechanism of circulating immune complex glomerulonephritis. HBV is a spherical particle (dane particle) with a diameter of 42-45nm, consisting of a double shell and an inner core, containing double-stranded DNA and DNA polymerase. One negative strand is a long chain of about 3.2kb, and the other positive strand is a short chain of about 2.8kb. The long chain DNA has four reading frames, encoding HBsAg, HBcAg, HBeAg, DNA polymerase, and X protein. In hepatitis B virus-associated glomerulonephritis, the main antigens deposited in the glomerular capillary wall are HBsAg and HbeAg. Ozawa and Hattor have respectively eluted and found anti-HBsAg antibody and anti-HBeAg antibody from the renal tissue of HBV-GN patients; immunoelectron microscopy shows that the above HBV antigens and immunoglobulins are deposited at the same site in the glomeruli, which all support that HBV-GN is an immune complex glomerulonephritis caused by HBV antigen components.

　　The complications caused by hepatitis B virus-associated glomerulonephritis (HBV-GN) mainly include renal insufficiency, hypertension, chronic hepatitis, and liver failure, as follows:

　　1. Renal insufficiency

　　Caused by various reasons, the severe destruction of glomeruli leads to a clinical syndrome complex in which the body appears to be disordered in excreting metabolic waste and regulating water and electrolyte balance, acid-base balance, etc. It is divided into acute renal insufficiency and chronic renal insufficiency. The prognosis is serious, and it is one of the main diseases that threaten life. Renal insufficiency can be divided into four stages: renal reserve compensation period, renal insufficiency period, renal failure period, and uremia period.

　　2. Hypertension

　　Refers to the increase in systolic blood pressure and/or diastolic blood pressure at rest (>=140/90mmHg), often accompanied by disorders of fat and sugar metabolism, as well as functional or organic changes in the heart, brain, kidneys, and retina, and a systemic disease characterized by organ remodeling. Clinically, many patients with hypertension, especially those with obesity, often have diabetes, and diabetes also often has hypertension, so both are called homologous diseases.

　　3. Chronic hepatitis

　　Due to the long-term treatment of acute hepatitis B and acute hepatitis C, the course of the disease exceeds half a year and turns into chronic hepatitis. Common symptoms include loss of appetite, fatigue, abdominal distension, abdominal pain, and costal pain, etc.

　　4. Liver function failure

　　A clinical syndrome that occurs due to widespread and severe damage to liver cells and severe disruption of metabolic function in the body, abbreviated as liver failure. Liver failure occurs in many severe liver diseases, with dangerous symptoms and a poor prognosis. Patients usually have symptoms such as jaundice, hepatic encephalopathy, hemorrhage, cerebral edema, pulmonary edema, and ascites.

　　Hepatitis B virus (HBV) related glomerulonephritis usually occurs in children and adolescents, with a higher prevalence in males, and the clinical manifestations are diverse, as follows:

　　1. Renal manifestations

　　The clinical manifestations of HBV-related glomerulonephritis are diverse, mainly presenting as nephrotic syndrome or glomerulonephritis syndrome. The onset is often insidious, with varying degrees of edema and fatigue. All patients can have microscopic hematuria or proteinuria, with some patients starting with nephrotic syndrome and some patients having a large amount of ascites. 40% have hypertension, and 20% have renal insufficiency.

　　2. Extra-renal manifestations

　　Most patients have normal liver function, while some patients may have chronic persistent hepatitis, chronic active hepatitis, severe hepatitis, or even liver cirrhosis, leading to corresponding clinical manifestations. Almost all patients have positive HBsAg in their blood, with 60% to 80% positive HBeAg, and some patients have abnormal liver function and elevated transaminases. A few patients may have low complement levels and cryoglobulinemia.

　　The pathological types of HBV-related glomerulonephritis are diverse, with the most common being HBV-related membranous nephropathy, followed by HBV-related membranoproliferative glomerulonephritis. HBV-related membranous nephropathy has its characteristics, and some believe that this type of HBV-related membranous nephropathy has both the pathological characteristics of idiopathic membranous nephropathy and the pathological features of mesangial proliferative glomerulonephritis. Some authors also call it atypical membranous nephropathy.

　　The key to preventing hepatitis B virus-related glomerulonephritis (HBV-GN) lies in the active prevention and treatment of hepatitis B, especially perinatal vertical infection. In recent years, significant progress has been made in the research of hepatitis B vaccine, which has been listed in the planned immunization program and widely applied, creating good conditions for the prevention and treatment of hepatitis B. To prevent perinatal vertical infection, long-term follow-up observation of recipients of hepatitis B vaccine has been carried out, with 47 out of 53 cases (89%) showing positive HBs antibody after the age of 5, and no HBs antigen-positive cases were found, achieving good results. It is believed that in the near future, with the control of hepatitis B, the incidence of this disease will inevitably decrease.

　　The clinical examination methods for hepatitis B virus-related glomerulonephritis (HBV-GN) mainly include urine examination, blood biochemistry, hepatitis B serological markers, immunological examination, and renal biopsy, as follows:

　　1. Urine

　　Hematuria and proteinuria, as well as tubular casts, may occur, with the main urine protein being albumin.

　　2. Blood biochemistry

　　There is often a decrease in albumin, an increase in cholesterol, and the alanine aminotransferase and aspartate aminotransferase may be elevated or normal. The plasma protein electrophoresis α2 and β-globulin are elevated, while γ-globulin is often normal.

　　3, Hepatitis B serological markers and HBV-DNA

　　Most patients are positive for hepatitis B大三阳 (HBsAg, HBeAg, and HBcAb), a few patients are positive for hepatitis B小三阳 (HBsAg, HbeAb, and HBcAb), and very few patients are positive for HBsAg alone. HBV-DNA in the blood is generally positive.

　　4, Immunological examination

　　There may be hypocomplementemia and cryoglobulinemia, with about 50% of patients having reduced complement levels in the blood, and increased blood IgG and IgA, indicating that the lesion is in an active state. Circulating immune complexes are positive in the blood. HBsAg, HBcAb, HBeAg, HBeAb, DNA polymerase (DNA-P), and HBV-DNA are detected in the blood, among which HBeAg, DNA polymerase (DNA-P), and HBV-DNA are currently considered the most sensitive indicators for the diagnosis of HBV infection. However, HBsAg positivity can support the diagnosis of hepatitis B-related nephropathy, or it may also indicate the coexistence of two independent diseases, hepatitis B and glomerulonephritis. Therefore, HBsAg should be routinely checked in patients with glomerulonephritis to avoid missing the diagnosis and delaying treatment.

　　5, Renal biopsy

　　It is the ultimate means to determine HBV-GN and is a necessary condition for the diagnosis of HBV-GN. HBV infection has organotropicity, affecting not only the liver but also the kidneys, causing renal damage. The pathological types of renal HBV-related glomerulonephritis show a variety of manifestations, the most common being membranous glomerulonephritis, followed by membranoproliferative glomerulonephritis, mesangial proliferative glomerulonephritis, focal segmental mesangial proliferation or focal segmental sclerosis glomerulonephritis, and IgA nephropathy, etc. In pathological histology, the HBV-related glomerulonephritis of each pathological type is similar to the primary glomerulonephritis of the corresponding type.

　　Diagnosis of HBV-related glomerulonephritis must be performed by renal tissue biopsy, as the positivity of serum HBV antigen is not sufficient to serve as the basis for the diagnosis of HBV-related glomerulonephritis. If HBV antigen is detected in renal tissue sections of patients with nephritis, and after excluding lupus nephritis, idiopathic membranous nephropathy, and other kidney diseases, the diagnosis of HBV-related glomerulonephritis can be made. Immunofluorescence examination shows deposits of HBsAg, IgM, IgG, and C3 in the glomerular capillary loops and mesangial area. Some authors have also reported the deposition of HBeAg and HBcAg in the glomeruli. Electron microscopy examination of HBV-related glomerulonephritis sometimes shows viral-like particles and tubular reticular inclusions, suggesting that the disease is related to viral infection.

　　6, Others

　　Routine ultrasound, electrocardiogram, and other examinations should be performed.

　　The hepatitis B virus-associated glomerulonephritis (HBV-GN) should consume high-protein, nutritious, rich in vitamins and minerals, and easily digestible high-calorie foods; avoid greasy, difficult-to-digest, fried, smoked, grilled, cold,刺激性 and high-salt, high-fat foods. Since alcohol can damage the liver and latent viruses can also damage the liver, they can promote liver cell damage, so hepatitis B patients are strictly prohibited from drinking alcohol.

　　As modern medicine lacks effective treatment for hepatitis B virus-related glomerulonephritis (HBV-GN), this disease should be mainly treated with traditional Chinese medicine. Traditional Chinese medicine believes that the liver and kidney are of the same origin, and the essence and blood of the liver and kidney transform and nourish each other. The etiology of hepatitis B virus-related glomerulonephritis is hepatitis B virus, and current research believes that it belongs to dampness and heat toxins. Considering that the occurrence of this disease is related to liver viral infection, preventing and clearing hepatitis B virus in the body and preventing further kidney damage is the key to treating this disease. The specific treatment with traditional Chinese medicine is as follows:

　　1. Liver depression and spleen deficiency, internal dampness and heat

　　Treatment Method: Soothe the liver and invigorate the spleen, clear dampness and heat and detoxify.

　　Prescription: Modified Chaihu Shugan Powder combined with Huanglian Jiedu Decoction. Medicines include vinegar Chaihu, red and white peony, Angelica sinensis, fructus aurantii, Coptis chinensis, Gardenia, Pinellia ternata, talc, artemisia, plantago seed, semicarpus, rhizoma Polygoni Cuspidati, white mouth grass, amomum, amomum villosum, etc.

　　2. Yin deficiency of the liver and kidney, dampness and heat linger

　　Treatment Method: Nourish the liver and kidney, clear dampness and heat.

　　Prescription: Modified Zhizi Dihuang Decoction. Medicines include anemarrhena, Phellodendri Chinensis, raw earth, Shanyao, Shanyao, poria, alisma, moutan bark, Schisandra chinensis, Cynanchum wilfordii, talc, white mouth grass, motherwort, white mugwort root, etc.

　　3. Deficiency of both Qi and Yin, dampness and blood stasis block the channels

　　Treatment Method: Invigorate Qi and nourish Yin, activate blood and promote diuresis.

　　Prescription: Modified Shenqi Dihuang Decoction or Dabuyuan Decoction. Medicines include Taiizi, raw astragalus, raw earth, moutan bark, red peony, poria, alisma, salvia miltiorrhiza, shiwei, talc, plantago seed, motherwort, white mugwort root, white mouth grass, rhizoma Polygoni Cuspidati, rhizoma Cynanchi, motherwort, white mugwort root, etc.

　　4. Yang deficiency of the spleen and kidney, water dampness泛滥

　　Treatment Method: Warm and tonify the spleen and kidney, promote diuresis and swelling reduction.

　　Prescription: Modified Shenshuang Drink, Zhenshuang Decoction or Jisheng Shenqi Decoction. Medicines include prepared aconite, atractylodes, poria, Rhizoma Alismatis, white peony root, rhizoma Stephaniae Tetrandrae, pericarpium Citri Reticulatae, plantago seed, cowherb, rhizoma Cynanchi, fried duzhong, etc.

　　Common herbs that increase the inhibitory effect on hepatitis B virus include dandelion, papaya, firebush, grasshopper, summer grass, gentian, purple herb, northern chrysanthemum, rhizoma Polygoni Cuspidati, rhizoma Cynanchi, Phellodendri Chinensis, Gardenia, patrinia, indigo, etc.