乙型肝炎表面抗原阳性患者肾移植21例

目的 总结分析乙型肝炎表面抗原(HBsAg)阳性对肾移植受者肾功能的影响以及抗乙型肝炎病毒(HBV)治疗的时机.方法 肾移植术前HBsAg阳性者21例,其乙型肝炎核心抗体(抗-HBc)阴性,乙型肝炎e抗体(抗-HBe)阴性,HBV DNA定量<105拷贝/L,肝脏B型超声波检查无异常发现.供、受者HLA抗原错配数≤3,淋巴细胞毒交叉配合试验<0.10.术后采用环孢素A(CsA)、霉酚酸酯和甲泼尼龙预防排斥反应.11例术后肠道功能恢复后立即口服拉米夫定100 mg/d,另10例在随访过程中发现肝功能异常、HBV DNA升高时,给予拉米夫定100 mg/d,同时减少CsA和糖皮质激素的剂量,并行护肝治疗.结果 10例经抗病毒和护肝治疗后,丙氨酸转氨酶(ALT)和HBV DNA于术后1年左右恢复至正常水平.预防性口服拉米夫定者的HBV DNA均保持在106拷贝/L以下,ALT正常或稍高(未超出正常值的2倍).采用拉米夫定预防性治疗者术后2年内的肾功能优于未预防性治疗者(P<0.05).结论 HBsAg阳性并非肾移植的禁忌证,术后早期行预防性抗病毒治疗可有效避免肝功能异常,也有利于改善移植肾功能.

Renal transplantation of 21 cases positive for HBsAg

Objective To analyze the outcome of allograft function of the HBsAg(+) recipients and discuss the suitable time of antiviral therapy. Methods Twenty-one HBsAg(+) recipients were randomly divided two groups: one group (11 cases) taking lamivudine orally after recovery of intestinal function, and another group (10 cases) taking lamivudine orally when liver dysfunction and increased HBV-DNA (HBV-DNA>106 copies/L) occurred during the period of follow-up. Liver function, allograft function, and hepatitis virus reactivation were followed up for 2 years after transplantation. Results Hepatitis recurrence and liver dysfunction after renal transplantation lay in viral replication after immuno-suppression. Lamivudine therapy accomplished the goals of viral suppression, and normalization of alanine aminotransferase (ALT) levels. Preemptive lamivudine therapy for recipients had a better liver and allograft function than oral administration for patients with liver dysfunction and increased HBV-DNA copies during a period of the two-years follow-up. Conclusion HBsAg (+) is not contraindication of renal transplantation. Preemptive lamivudine therapy early after operation could avoid liver dysfunction and improve the renal allograft function during the period of two-years follow-up.