Active vaccination to prevent de novo hepatitis B virus infection in liver transplantation

The shortage of organ donors mandates the use of liver allograft from anti-HBc(+) donors, especially in areas highly endemic for hepatitis B virus(HBV) infection. Theincidence of de novo hepatitis B infection(DNH) is over 30%-70% among recipients of hepatitis B core antibody(HBcA b)(+) grafts without any prophylaxis after liver transplantation(LT). Systematic reviews showed that prophylactic therapy [lamivudine and/or hepatitits B immunoglobulin(HBIG)] dramatically reduces the probability of DNH. However, there are limited studies regarding the effects of active immunization to prevent DNH, and the role of active vaccination is not welldefined. This review focuses on the feasibility and efficacy of pre- and post-LT HBV vaccination to prevent DNH in HBsA g(-) recipient using HBcA b(+) grafts. The presence of HBs Ab in combination with lamivudine or HBIG results in lower incidence of DNH and may reduce the requirement of HBIG. There was a trend towards decreasing incidence of DNH with higher titers of HBs Ab. High titers of HBs Ab(> 1000 IU/L) achieved after repeated vaccination could eliminate the necessity for additional antiviral prophylaxis in pediatric recipients. In summary, active vaccination with adequate HBsA b titer is a feasible, cost-effective strategy to prevent DNH in recipients of HBc Ab(+) grafts. HBV vaccination is advised for candidates on waiting list and for recipients after withdrawal of steroids and onset of low dose immunosuppression after transplantation.

吲哚胺2，3双加氧酶在诊断肝移植急性排斥中的作用

目的探讨外周血吲哚胺2，3双加氧酶（IDO）基因表达对大鼠肝移植急性排斥反应（AR）的诊断价值。方法建立大鼠原位肝移植模型，分为4组：A组：同基因移植组（Wistar—Wistar，n=32）；B组：异基因移植组（SD—Wistar，n=32）；C组：异基因移植＋长期环孢素A组（CsA，n=32）；D组：异基因移植＋短期CsA组（用药剂量同C组，第3天起停药，n=32）。应用实时聚合酶链反应（Real—timePCR）方法分别检测术后第0、1、2、3、4、5、7、9天外周mIDO mRNA值，同时检测各时间点血清谷草转氨酶（AST）、总胆红素（T—BIL）、碱性磷酸酶（ALP）水平，并取肝脏病理切片。结果A组外周血IDO mRNA呈持续低水平，AST、T—BIL、ALP逐渐降至正常，病理无排斥反应。C组检测结果与A组相似。B组IDO mRNA显著上升为术后第2天（P〈0．05），AST、T—BIL、ALP值显著上升为术后4d（P〈0．01），病理切片判断轻度排斥为术后5d（χ^2=4．8，P〈0．05）。D组IDOmRNA显著上升为术后第4天（P〈0．05），AST、T—BIL、ALP值显著上升为术后5d（P〈0．01），病理切片判断轻度排斥为术后7d（χ^2=4．8，P〈0．05）。结论外周血IDO mRNA检测可较病理检查更早诊断大鼠肝移植AR的发生，且方法简单、安全。

胆管空肠吻合术重建胆道对肝移植患者术后胆道并发症的影响

目的探讨肝移植术中采用胆管空肠吻合术重建胆道对患者术后胆道并发症发生的影响。方法本组回顾性研究对象为2003年10月至2009年7月在中山大学附属第三医院肝移植中心实施原位肝移植术的765例患者。患者均签署知情同意书,符合医学伦理学规定。按胆道重建方式将患者分为胆管空肠吻合术组(胆肠吻合组)52例和胆管端端吻合术组(端端吻合组)713例。统计两组肝移植术后胆漏、胆管狭窄及胆泥或结石等胆道并发症发生率。采用χ2检验比较两组胆道并发症发生率。结果本组765例肝移植术后患者共有132例发生胆道并发症,术后胆道并发症总的发生率为17.3%(132/765),胆漏、胆管狭窄和胆泥或结石的发生率分别为2.4%(18/765)、16.3%(125/765)和4.6%(35/765)。胆肠吻合组胆漏、胆管狭窄和胆泥或结石的发生率分别为6%(3/52)、21%(11/52)和8%(4/52),端端吻合组分别相应为2%(15/713)、16%(114/713)和4%(31/713)。两组患者术后胆漏、胆管狭窄和胆泥或结石的发生率比较,差异无统计学意义(均为P>0.05)。两组吻合口狭窄和非吻合口狭窄比例比较差异亦无统计学意义(χ2=0.374、2.661,均为P>0.05)。结论与胆管端端吻合术比较,肝移植患者术中采用胆管空肠吻合术并未增加术后胆道并发症发生率,两种术式均为胆道重建的有效方法,胆肠吻合术可以作为胆管端端吻合术的有益补充。