合并乙型肝炎病毒感染的心脏移植患者的处理

目的总结合并乙型肝炎病毒(HBV)感染的心脏移植患者的处理体会。方法11例心脏移植患者中,10例术前合并HBV感染,1例术后5年继发HBV感染。11例患者均存在肝功能受损。给予保肝治疗后,心脏移植前肝功能明显好转。2例患者术前即开始口服环孢素A(CsA),术后长期口服CsA、硫唑嘌呤(Aza)及泼尼松(Pred)预防排斥反应;9例术后应用CsA、Aza(或霉酚酸酯)及激素预防排斥反应,并应用达利珠单抗进行免疫诱导治疗,共用达利珠单抗5剂,激素于术后1个月停用。结果11例患者中,1例于术后3个月并发肺部曲菌感染,开胸手术切除病灶,但患者最终死于爆发性肝功能衰竭;1例于术后23个月冈严重肝硬化并发顽固性低蛋白血症和腹水,行肝移植,术后恢复顺利;1例因反复发生肝功能异常,血CsA浓度极不稳定,术后1年死于急性排斥反应;7例术后随访1～3年,肝功能大多时候正常,偶有转氨酶和胆红素轻度升高,此时血CsA浓度常超出预期值,通过调整CsA的用量,同时辅以保肝治疗,肝功能均恢复正常;1例术后5年继发HBV感染,在保肝治疗的同时,给予拉米夫定抗病毒治疗,肝功能恢复正常,患者至今已存活8年。结论术前合并HBV感染并非心脏移植手术的绝对禁忌证,只要处理得当,就可行心脏移植,术后患者可长期存活。

Experience in the management of HBV infection following heart transplantation

Objective To Sum up the clinical experience in the management of HBV infection following heart transplantation. Methods In 11 cases of heart transplantation, 10 cases suffered from preoperative HBV infection and 1 case from secondary HBV infection 5 years after operation. Two cases received standard immunosuppressive regime consisting of cyclosporine, azathioprine, and prednisolone, and 9 cases received an induction therapy with the monoclonal anti-interleukin-2 receptor antibody daclizumab (Zenapax), and postoperative immunosuppression was maintained with oral cyclosporine, azathioprine or mycophenolate mofetil and the withdrawal of prednisolone at one month after transplantatioa Results One case died of hepatic dysfunction because of pulmonary fungus infection for 3 months survival. One case was subjected to liver transplantation due to hypoproteinemia and refractory ascites because of severe hepatic cirrhosis at 23rd month after heart transplantatioa One case died of acute rejection for one year survival because of the instability of the CsA level and the hepatic dysfunction. The hepatic function was normal for the other 7 cases with 1-3 years long-term outcome. One case for 8 years survival suffered from HBV infection at 5th year after heart transplantation and the hepatic function was normal after lamivudine therapy. Conclusion Preoperative HBV infection was not the contraindication for heart transplantation.