肝癌肝移植术前应用PD-1抑制剂后发生急性排斥反应一例并文献复习  

Acute rejection after application of PD-1 inhibitor before liver transplantation for hepatocellular carcinoma:one case report and literature review

作　　者：冯军 艾麦提·牙森 梁润斌 廖志洪 赵超尘[1] 谢嘉奋 朱灿华[1] 罗燕君[1] 汪国营 Feng Jun;Aimaiti·Yasen;Liang Runbin;Liao Zhihong;Zhao Chaochen;Xie Jiafen;Zhu Canhua;Luo Yanjun;Wang Guoying(Department of Hepatobiliary Surgery,the First Affiliated Hospital of Guangzhou Medical University,Guangzhou 510120,China)

机构地区：[1]广州医科大学附属第一医院肝胆外科,510120

出　　处：《中华肝脏外科手术学电子杂志》2024年第1期88-92,共5页Chinese Journal of Hepatic Surgery(Electronic Edition)

基　　金：广东省自然科学基金面上项目(2022A1515010519);广州市基础研究计划市校(院)联合资助项目(202201020439);广州市临床特色技术(2023C-TS18)。

摘　　要：目的探讨肝细胞癌(肝癌)肝移植术前应用PD-1抑制剂的安全性。方法回顾性分析2021年5月12日在广州医科大学附属第一医院行PD-1抑制剂联合TACE及局部放疗后行肝移植术的1例肝癌患者临床资料。患者签署知情同意书,符合医学伦理学规定。总结患者术前情况,术后病情变化特点及可能原因,并进行相关文献复习。结果患者有肝癌家族史及嗜酒史,术前CT示肝右叶占位,最大径约8.8 cm,考虑肝细胞癌伴门静脉右前支癌栓,肿瘤分期为CNLCⅢa期。术前行TACE治疗2次,替雷利珠单抗(200 mg Q21d)治疗5个周期,肝癌降期成功后行肝移植术,术后予他克莫司+吗替麦考酚酯胶囊+糖皮质激素三联抗排斥方案。术后第8天出现TB、ALT和AST不可逆升高,考虑肝移植术后急性排斥反应,采用激素冲击治疗及对症处理后疗效不佳,术后第13天死于肝衰竭、呼吸衰竭、肾衰竭等多器官衰竭。结论应用PD-1抑制剂作为肝癌肝移植术前降期治疗手段需十分慎重,已应用PD-1抑制剂者肝移植术后应加强免疫抑制治疗和免疫功能监测。Objective To evaluate the safety of application of PD-1 inhibitor before liver transplantation(LT)for hepatocellular carcinoma(HCC).Methods Clinical data of 1 patient with HCC who underwent LT after PD-1 inhibitor combined with TACE and local radiotherapy in the First Affiliated Hospital of Guangzhou Medical University on May 12,2021 were retrospectively analyzed.The informed consents of the patient were obtained and the local ethical committee approval was received.Preoperative conditions,postoperative changes characteristics of the disease and possible causes were summarized,and literature review was conducted.Results The patient had a family history of HCC and alcohol addiction.Preoperative CT scan showed a space-occupying mass in the right lobe with a maximum diameter of 8.8 cm.The possibility of HCC complicated with the right anterior portal vein tumor thrombus was considered.The patient was diagnosed with stageⅢa HCC based on China liver cancer(CNLC)staging system.Preoperatively,TACE was performed twice.Tislelizumab(200 mg,Q21d)was given for 5 cycles.LT was performed after successful down-staging,and anti-rejection regimen of tacrolimus+mycophenolate mofetil capsule+glucocorticoids was given after surgery.Irreversible elevation of TB,ALT and AST levels occurred at postoperative 8 d.The possibility of acute rejection after LT was considered.Hormone shock therapy and symptomatic treatment yielded low efficacy.At postoperative 13 d,the patient died from multiple organ failure,such as liver failure,respiratory failure and kidney failure.Conclusions Cautions should be taken when using PD-1 inhibitor as a down-staging approach for HCC before LT.For patients who have been given with PD-1 inhibitor,immunosuppressive therapy and immune function monitoring should be strengthened after LT.

关 键 词：癌 肝细胞 肝移植 降期治疗 PD-1抑制剂 急性排斥反应 

分 类 号：R735.7[医药卫生—肿瘤]