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肝脏移植治疗慢性乙型肝炎病毒感染

Author
Anna SF Lok, MD
Section Editor
Robert S Brown, Jr, MD, MPH
Deputy Editor
Anne C Travis, MD, MSc, FACG, AGAF
Translators
杨文卓, 主任医师，副教授

引言

慢性乙型肝炎病毒(hepatitis B virus, HBV)感染的治疗虽取得了一定进展，但肝脏移植仍是许多HBV所致终末期肝病患者的唯一希望。一项对核苷(酸)类似物使用前时代中HBV相关肝硬化的自然病程的研究显示，整组患者的5年生存率为71%，但失代偿期肝硬化患者的5年生存率仅为14%(图 1)[1]。

20世纪80年代，肝脏移植治疗慢性乙型肝炎的最初结果令人失望，其移植物再感染率接近80%-100%[2-4]。很多患者的再感染引起严重且进展迅速的肝脏疾病，致使其移植物和患者2年生存率为50%，而在因其他类型慢性肝病行肝脏移植的患者中为80%[5]。鉴于移植结果不佳和供体器官供应有限，很多医疗中心和第三方支付者放弃对慢性乙型肝炎患者进行肝脏移植[6]。

自20世纪80年代晚期以来，由于引入了采用乙型肝炎免疫球蛋白(hepatitis B immune globulin, HBIG)和其后的核苷(酸)类似物等策略的有效措施来预防和治疗再感染，肝脏移植的结局得到了显著改善[7-10]。目前，HBV相关肝硬化患者行肝脏移植在1年时的总体生存率超过85%，在5年时的总体生存率超过75%[7,10-13]。另外，因HBV相关终末期肝病而行肝移植的比率也显著下降，2006年肝移植等候名单登记人数比1999年下降了47%[14]。

肝脏移植后的HBV再感染

肝脏移植后HBV再感染率较高的原因可能在于，免疫抑制导致病毒复制增强，以及类固醇治疗对HBV基因组中糖皮质激素反应性增强子区的直接刺激作用[15,16]。HBV的肝外寄居处，如外周血单个核细胞、脾脏和其他器官，也可能促使移植物再感染[17]。

再感染的危险因素 — 有资格进行肝脏移植的HBV相关肝硬化患者可被概念性地分为再感染高危组与再感染低危组。

                           

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Literature review current through: 2017-06 . | This topic last updated: 2016-01-12.
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