不同风险人群肝移植术后预防乙型肝炎复发治疗17年的疗效研究  

17-year study on the curative effect of treatment to prevent the recurrence of hepatitis B in different risk groups after liver transplantation

作　　者：张达利 贺希 冯丹妮 任敏娟 光永辉 李丽昕 王洪波 刘振文 Zhang Dali;He Xi;Feng Danni;Ren Minjuan;Guang Yonghui;Li Lixin;Wang Hongbo;Liu Zhenwen(Liver Disease Department,The Fifth Medical Center of PLA General Hospital,Beijing 100039,China)

机构地区：[1]解放军总医院第五医学中心肝病医学部,北京100039

出　　处：《中华肝脏病杂志》2024年第1期22-28,共7页Chinese Journal of Hepatology

摘　　要：目的观察不同风险人群在肝移植术后乙型肝炎的复发情况,为以后是否早期停用乙型肝炎免疫球蛋白(HBIG)提供有用信息。方法根据肝移植术后乙型肝炎复发防治指南分为高、低风险人群及特殊人群[尤其原发性肝细胞癌(HCC)],观察这部分人群乙型肝炎复发情况及复发的危险因素。计量资料组间比较采用t检验、秩和检验;计数资料组间比较采用χ^(2)检验。结果最终纳入532例乙型肝炎相关肝移植患者。肝移植术后共35例出现HBV复发,其中HBsAg阳性34例,HBsAg阴性1例,乙型肝炎病毒(HBV)DNA阳性10例。乙型肝炎总的复发率为6.6%。术前HBV DNA阳性的高风险人群乙型肝炎的复发率为9.2%,HBV DNA阴性低风险人群的复发率为4.8%(P=0.057)。肝移植术前诊断为HCC的293例患者中术后30例出现乙型肝炎复发,复发率为10.2%。HCC患者肝移植术后乙型肝炎复发的独立相关因素为HCC复发(HR=181.92,95%CI 15.99~2069.96,P<0.001)、术后吗替麦考酚酯分散片(MMF)剂量高(HR=5.190,95%CI 1.289~20.889,P=0.020)和HBIG用量大(HR=1.012,95%CI 1.001~1.023,P=0.035)。肝移植术前非HCC的239例患者中5例患者出现术后乙型肝炎复发(复发率为2.1%),均为术后应用拉米夫定联合按需HBIG预防治疗的患者,术后恩替卡韦联合HBIG的非HCC患者没有乙型肝炎复发。结论肝移植术后高耐药屏障核苷酸类似物联合长期HBIG预防乙型肝炎复发效果好。对于低风险患者给予高耐药屏障核苷酸类似物后可考虑早期停用HBIG;对于高风险患者,特别是HCC的高风险患者,国内HBV感染率高,尚需进一步研究探索HBIG停药时机。Objective To observe the recurrence condition of hepatitis B in different risk groups after liver transplantation in an attempt to provide useful information on whether to discontinue hepatitis B immunoglobulin(HBIG)in the future at an early stage.Methods The patient population was divided into high,low-risk,and special groups[especially primary hepatocellular carcinoma(HCC)]according to the guidelines for the prevention and treatment of hepatitis B recurrence after liver transplantation.The recurrence condition and risk factors in this population were observed for hepatitis B.Measurement data were analyzed using a t-test and a rank-sum test.Count data were compared using aχ^(2) test between groups.Results This study finally included 532 hepatitis B-related liver transplant cases.A total of 35 cases had HBV recurrence after liver transplantation,including 34 cases that were HBsAg positive,one case that was HBsAg negative,and 10 cases that were hepatitis B virus(HBV)DNA positive.The overall HBV recurrence rate was 6.6%.The recurrence rate of HBV was 9.2%and 4.8%in the high-and low-risk HBV DNA positive and negative groups before surgery(P=0.057).Among the 293 cases diagnosed with HCC before liver transplantation,30 had hepatitis B recurrence after surgery,with a recurrence rate of 10.2%.The independent related factors for the recurrence of hepatitis B in patients with HCC after liver transplantation were HCC recurrence(HR=181.92,95%CI 15.99~2069.96,P<0.001),a high postoperative dose of mycophenolate mofetil dispersible tablets(MMF)(HR=5.190,95%CI 1.289~20.889,P=0.020),and a high dosage of HBIG(HR=1.012,95%CI 1.001~1.023,P=0.035).Among the 239 cases who were non-HCC before liver transplantation,five cases(recurrence rate of 2.1%)arouse postoperative hepatitis B recurrence.Lamivudine was used in all cases,combined with on-demand HBIG prophylaxis after surgery.There was no hepatitis B recurrence in non-HCC patients who treated with entecavir combined with HBIG after surgery.Conclusion High-barrier-to-resistance nucl

关 键 词：肝移植 乙型肝炎 肝细胞癌 乙型肝炎免疫球蛋白 复发 危险因素 

分 类 号：R512.62[医药卫生—内科学]