肝移植受者乙型肝炎复发的因素分析

Clinical analysis of viral hepatitis B recurrence after liver transplantation for HBV-related liver diseases

目的探讨原发性肝细胞性肝癌、失代偿期肝硬化和急性肝功能衰竭患者肝移植后乙型肝炎复发的因素。方法回顾性收集、随访、分析因原发性肝细胞性肝癌、失代偿期肝硬化和急性肝功能衰竭而首次接受肝移植患者的资料。人组599例受者，移植后存活至少12个月并没有失随访。对其围手术期及移植术后预防乙型肝炎复发的治疗方案、移植术后乙型肝炎复发的发生及时间，移植术后乙型肝炎复发的影响因素，以及预后进行分析。结果599例中，36例肝移植后乙型肝炎复发，其中肝移植原发病为原发性肝细胞性肝癌者复发23例[复发率为7．2％（23／319）]，失代偿期肝硬化者复发13例[复发率为5．6％（13／232）]，急性肝功能肝衰竭者移植后无乙型肝炎复发（复发率为0）。599例受者肝移植后1年内的乙型肝炎累积复发率为2．3％，5年累积复发率为5．5％，8年累积复发率为6％。移植后使用恩替卡韦单药者和两种核苷酸类似物（NAs）联合用药者的乙型肝炎累积复发率明显低于使用拉米夫定者，复发率分别为2．9％（8／280）、3．2％（6／186）和16．5％（22／133）（P〈0．05）。结论原发性肝细胞性肝癌和失代偿期肝硬化是肝移植后乙型肝炎复发的高危原发疾病。恩替卡韦单药或两种NAs抗病毒药物联合用药方案对于预防肝移植术后乙型肝炎复发的疗效优于拉米夫定单药。

Objective To study the recurrence risks of viral hepatitis B （VHB） after liver transplantation for hepatitis B virus （HBV）-related liver diseases. Methods A total of 599 patients undergoing liver transplantation due to HBV-related liver disease Ehepatic cellular cancer （HCC）, decompensated liver cirrhosis （DLC）, acute liver failure （ALF）] were included in this study. All patients included in this study have been followed up for at least 12 month for liver biochemistry and HBV testing, altogether with the clinic presentation and outcomes. Treatment protocols about prevention of VHB recurrence in perioperative period and after liver transplantation, the time interval and influence factors of VHB recurrence, and the disease prognosis were analyzed. Results Of the 599 patients, 36 cases of VHB recurrence were observed. The rate of VHB recurrence was 7.2% （23/319）, 5.6% （13/232） and 0 （0/48） for HCC, DLC and ALF, respectively. The rates of VHB recurrence were 2. 3%, 5.5%, 6% for 1 year, 5 years and 8 years, respectively. The rate of VHB recurrence in the lamivudine group was significantly higher than in enticavir group and combination therapy group [16. 5% （22/133）, 2. 9% （8/280）, and 3.2% （6/186）, respectively, P〈0.05 for all]. Conclusion HCC and DLC as liver transplant indications are independent risk factors for VHB recurrence after liver transplant. For liver transplant patients with HBV-related liver disease, enteeavir monotherapy and combination therapy （lamivudine and adefovir, or tenofovir） are both more effective on the prophylaxis of VHB recurrence than lamivudine monotherapy.