肾移植术后急性重型肝炎2例报告并文献复习

Acute severe hepatitis after renal transplantation:two cases report and literature review

目的探讨肾移植术后急性重型乙型病毒性肝炎(急性重型肝炎)的死亡原因、治疗及预防方法。方法回顾性分析2008年至2010年2例肾移植术后急性重型肝炎的临床资料。结果南方医科大学附属珠江医院2008年至2010年肾移植术后急性重型肝炎发生率0.2%(2/500)。2例患者中1例术前有乙型病毒性肝炎(乙肝)病史,另1例无乙肝病史但术前未行乙型肝炎病毒(HBV)脱氧核糖核酸(DNA)检查。2例术前均未接受抗HBV治疗。分别于术后4、9个月发病,查HBV标记物阳性和HBVDNA水平明显升高,确诊为急性重型肝炎。2例予停用免疫抑制药物,给予多烯磷脂酰胆碱、甘草酸二铵(甘利欣)护肝治疗,予恩替卡韦抗病毒治疗,其中1例加用血液灌流治疗。2例病情进展迅速,最终死于多器官功能衰竭。结论肾移植术后急性重型肝炎的发生率较低,但病情严重、进展迅速、疗效不佳、预后较差。该病以预防为主,确诊乙肝的患者术前、术后应口服敏感抗病毒药物,及时调整免疫抑制剂,定期复查肝功能、HBV标记物、HBVDNA定量,HBV标记物阴性者术前应接种乙肝疫苗,待抗体达到一定滴度后再行移植手术。

Objective To investigate the causes of death,treatment and prevention of acute severe hepatitis B after renal transplantation.Methods Clinical data of 2 patients with acute severe hepatitis B from 2008 to 2010 were retrospectively analysed.Results The incidence of acute severe hepatitis B after renal transplantation from 2008 to 2010 was 0.4%（2/500）in Affiliated Zhu Jiang Hospital of Southern Medical University.One of the two cases had a history of hepatitis B before renal transplantation,the other one had no history of hepatitis B,and his hepatitis B virus（HBV）deoxyribonucleic acid（DNA）was not detected before the operation.Neither of them had any antivirus treatment.Acute severe hepatitis B was diagnosed 4 and 9 months after renal transplantation respectively,with HBV markers positive and HBV DNA level increased.The immunosuppressant was suspended in both cases.Polyene phosphatidylcholine and diammonium glycyrrhizinate were used for liver protection.Entecavir was used for antivirus treatment.One of them received hemoperfusion.But the two patients＇ condition worsened rapidly and finally they died of multiple organ failure.Conclusions The incidence of acute severe hepatitis B after renal transplantation is low.But when it occurs,it is severe and rapidly progressive.The treatment will be ineffective and the prognosis will be poor.Prophylaxis of the disease is important.The recipient with hepatitis B should take sensitive antivirus drugs orally before and after transplantation.Immunosuppressant dose should be adjusted timely and liver function,HBV markers and HBV DNA be detected peroidically.For patients with negative HBV markers,HBV vaccine shuld be inoculated before transplantation.Renal transplantation should be performed till the HBV antibody is high enough.