肝移植术后乙型肝炎病毒再感染的预防与诊治

Prevention and treatment of HBV reinfection after liver transplantation

目的探讨肝移植术后HBV再感染的预防与诊治。方法回顾性分析1999年8月至2004年12月98例肝移植患者临床资料。其中40例术后采用拉米夫定（lamivudine，LAM）单用方案预防HBV再感染，58例采用LAM＋乙型肝炎免疫球蛋白（HBIg）联用方案。对HBV再感染者予以阿德福韦（adefovir，ADV）抗病毒治疗。结果17例肝移植患者出现HBV再感染，其中14例明确存在YMDD变异。术前血清HBVDNA阳性者术后2年HBV再感染率显著高于阴性者（P〈0．05），前者术后采用LAM＋HBIg联合预防者其HBV再感染率显著低于单用LAM预防者（P〈0．05），而后者术后LAM单用和LAM＋HBIg联用两组之间差异无统计学意义（P〉0．05）。15例HBV再感染者改用ADV治疗后，13例（86．7％）于治疗后1～3个月HBVDNA转阴。结论术前降低血清HBVDNA水平和术后LAM＋HBIg联合预防方案能有效降低肝移植术后HBV再感染率。对术前HBVDNA阴性者，术后可选用LAM单药预防方案。ADV能够有效地治疗肝移植术后HBV再感染，抑制HBV变异株的复制。

Objective To study the prevention and treatment of HBV reinfection after liver transplantation. Methods A retrospective study was carried out on 98 patients who received orthotopic liver transplantation （OLT） from August 1999 to December 2004. Fifty-two patients were HBV DNA-positive and 46 HBV DNA-negative. All patients were divided into 4 groups： Group A [ HBV DNA-positive patients treated by lamivudine （ LAM）, n = 21 ], Group B （ HBV DNA-negative patients treated by LAM, n = 19 ）, Group C [ HBV DNA-positive patients treated by LAM ＋ Hepatis B immunoglobulin （HBIG）, n =31 ] and Group D （HBV DNA-negative patients treated by LAM ＋ HBIG, n = 27 ）. Adefovir dipivoxil （ADV） was administered to those patients who developed LAM-resistant HBV reinfection （YMDD）. Results Of all, 17 patients developed HBV reinfection after OLT but 14 of them were identified to be LAM-resistant HBV reinfection. The 2-year HBV reinfection rate was higher in HBV DNA-positive patients than HBV DNA-negative ones （ P 〈 0. 05 ）. The 2-year reinfection rate in Group C was significantly lower than that in Group A （ P 〈 O. 05 ）, while it showed no statistical difference between Group B and D. Fifteen HBV reinfection patients were given ADV treatment and HBV DNA negative conversion was observed in 13 patients after 1-3 months of treatment. Conclusions The HBV reinfection rate may be decreased by suppressing HBV DNA replication before OLT or applying the LAM ＋ HBIG therapy after OLT. LAM monotherapy is feasible for those patients with HBV DNA negative before OLT. ADV is effective for patients with LAM-resistant HBV by suppressing HBV variant replication.