肝移植术后持续高胆红素血症的诊治

Persistent hyperbilirubinemia in follow-up patients after liver transplantation

目的分析肝移植患者随访期间出现持续高胆红素血症的常见原因，总结诊治经验。方法对2000年5月至2009年12月在北京大学人民医院肝胆外科接受肝移植手术并在门诊随访的527例患者的临床资料进行回顾性分析。结果随访期间共有65例患者出现持续高胆红素血症，其病因分别为胆道并发症34例（52．3％），药物性肝损伤14例（21．5％），病毒性肝炎复发6例（9．2％），急性排斥反应4例（6．2％），十二指肠乳头炎性狭窄3例（4．6％），肝癌复发2例（3．1％），新发肿瘤和原因不明者各1例。通过保肝利胆药物治疗、调整或替换抗排斥药物、胆道镜取石和取栓、留置胆道引流和支撑管、以及再次进行外科手术后，65例患者中治愈或病情稳定者50例，死亡15例。结论肝移植患者随访期间出现黄疸的病因多样而复杂，容易导致诊治的延误。弥漫性肝内胆道狭窄的治疗效果较差，药物性肝损伤并不少见且诊断困难，需引起重视。

Objective To explore the etiologies of persistent hyperbilirubinemia in follow-up patients after liver transplantation. Methods The clinical data of 527 follow-up patients after liver transplantation at the department of hepatobiliary surgery in Peking University People＇s Hospital between May 2000 and Dec 2009 were analyzed retrospectively. Results Sixty-five patients experienced persistent hyperbilirubinemia, there were 34 cases of biliary complications （52. 3% ）, 14 cases with drug-induced liver injury（21.5% ） ,6 cases with hepatitis B or C recurrence（9. 2% ）, 4 eases with acute rejection （6. 2% ） 3 cases with inflammatory stenosis of the duodenal papilla （4. 6% ）, 2 cases with hepatic carcinoma recurrence（3. 1% ） , 1 case with neomalignancy and 1 case with unknown reason. Treatment included use of liver protectant and cholereties, the adjustment and replacement of anti-rejection drugs, cholelithotomy by choledoehoscope, PTCD, placement of biliary stent and re-operation. Of all the 65 cases 50 patients were cured or in stable condition, 15 patients died. Conclusions Jaundice is a common clinical manifestation after liver transplantation with multiple and complicated causes. Diffuse stricture of intrahepatic biliary tract predicts poor prognosis, drug-related liver injury was less common cause of hyperbilirubinemia and often misdiagnosed.