肾移植后纤维化淤胆性肝炎的临床病理特点

Clinical and histological features of fibrosing cholestatic hepatitis

目的 探讨纤维化淤胆性肝炎(fibrosing cholestatic hepatitis,FCH)临床病理特点和拉米夫定的防治效果。方法 回顾性分析我院794例肾移植后发生的17例重度黄疸性肝炎,其中6例经肝活检证实,2例有发病前后组织病理对比。结果 肾移植者中慢性HBV感染者为9.3％,其中FCH发生率为22.9％。肝活检证实的6例发病时间在移植后的1.5-22个月中。2例经拉米夫定治疗后缓解。4例慢性乙肝患者移植前后服用拉米夫定未发生纤维化淤胆性肝炎。移植后应用极大剂量多种免疫抑制剂,逐渐发生淤胆性肝炎和迅速进展肝功能衰褐;血清HBVDNA达极高水平;组织学表现独特的病变组合:肝细胞广范围气球样变性,毛玻璃样肝细胞不少见,区域性肝细胞溶解消失,淤胆,而炎症浸润轻微,并由汇管区发展的广范围纤维化。结论 肾移植后可发生纤维化淤胆性肝炎,拉米夫定对FCH有明显的即时治疗效应。

Objective To investigate the clinical and histological characteristics of fibrosing cholestatic hepatitis (FCH) and the therapeutic effect of lamivudine. Methods By retrospective analysis, 17 cases developed severe jaundice in 794 renal-transplanted recipients, and of them, FCH was clinically suggested in 11 and confirmed by liver biopsy in 6 cases. Results The prevalence of chronic HBV infection in renal transplantation patients was 9.3%, of whom the FCH occurred in 22.9%. In 6 liver-biopsied cases, the onset was within 1.5-22 months. Two cases remitted who had early received lamivudine and 4 cases who were treated with the drug before transplantation did not develop the disease. All patients received large amounts of multiple immuno-suppressors after transplantation. About one fifth of HBV-infected cases gradually developed cholestatic hepatitis and some of them rapidly proceeded to hepatic failure. All had very high serum level of HBV DNA. The histology revealed unique lesion combination. The hepatocytes had widespread ballooning change and some ground-glass appearance. There were liver cy-tolysis and focal cell loss, bile stasis, periportal fibrosis, while only mild lymphocytic infiltration. Conclusions Fibrosing cholestatic hepatitis may happen following renal transplantation. Lamivudine has marked therapeutic effect for FCH.