乙型肝炎病毒感染患者肾移植术后的治疗和预后分析

Therapies for recipients with hepatitis B virus infection after kidney transplantation:retrospective study of 21 cases

目的总结乙型肝炎病毒(HBV)感染患者肾移植术后的治疗和预后,以探讨合理的治疗措施。方法HBV感染肾移植患者21例,术前乙型肝炎病毒表面抗原(HBsAg)阳性和(或)HBV-DNA阳性。术后18例应用拉米夫定、3例应用恩替卡韦抗病毒治疗。随访3个月以上。3例肝肾联合移植的患者术后均使用乙型肝炎人免疫球蛋白。术后定期检测患者的肝功能,肝功能出现异常者及时应用护肝药物,必要时停用钙调磷酸酶抑制剂并对症处理,观察肾功能以及移植肾排斥反应、感染、预后等情况。结果术后随访3～75个月,中位时间17个月。21例中死亡5例,余均存活。12例(57%)术后出现不同程度的肝功能异常;经治疗恢复正常6例,好转3例,死亡3例。移植肾功能正常者13例,肾功能异常但未达到移植肾功能衰竭者6例,2例出现移植肾衰竭,重新恢复血液透析或腹膜透析。术后4例共发生5例次移植肾急性排斥反应,经应用甲泼尼龙冲击治疗或抗胸腺细胞球蛋白治疗后逆转。术后出现感染6例,均伴有肝功能明显异常,经治疗后4例治愈,2例死亡。结论HBV感染患者肾移植术后预防性应用抗HBV药物是必要的和有效的;合理使用免疫抑制剂、应用护肝药物可改善患者的预后。

Objective To investigate the reasonable therapies after kidney transplantation for recipients with hepatitis B virus infection by studying their treatments and prognosis. Methods Twenty-one cases were infected with hepatitis B virus and/or with HBV-DNA positive pre-operation. Eighteen patients were treated with lamivudine and 3 patients were treated with entecavir. All cases were followed up for at least 3 months. Three patients after liver-kidney united transplantation were also treated with hepatitis B immunoglobulin. Liver function tests were examined regularly. Hepatic protective drugs were given when patients had abnormal liver function. All cases were retrospectively analyzed, mainly focusing on liver function, kidney function, rejection, infection as well as prognosis. Results The follow-up time was 3 - 75 months （median 17 months）. Five recipients died and 16 survived in all 21 cases. Twelve patients suffered from abnormal liver function in different degrees. Six cases had normal liver function after effective hepatic protective drugs treatment. Three cases had improved liver function while another 3 cases died of liver failure. Thirteen recipients had normal renal function and six patients had abnormal renal function. Another two cases had graft failure and reverted after hemodialysis or peritoneal dialysis. Four cases experienced 5 acute rejection episodes and were reverted with high-dose of methylprednisolone or with antithymocyte globulin （ATG） treatment. Infections developed in 6 cases with abnormal liver function, Among them, 4 were cured and 2 were dead ＇after treatment. Conclusions It is essential and effective to treat recipients suffering from hepatitis B infection with anti-virus drugs after kidney transplanta- tion. The rational use of immunosupressants and hapato-protective drugs can improve prognosis of patients with HBV infection.