54例乙型肝炎病毒相关性肝病患者肝移植术后合并症的临床病理研究

目的:研究乙型肝炎病毒(hepatitis B virus,HBV)相关性肝病患者肝移植术后合并症的发生率,以及不同合并症发生的危险因素.方法:回顾性观察北京大学第三医院2000年8月至2004年8月期间54例HBV相关性肝病患者肝移植术后所有肝活检切片,并分析临床病例资料,研究肝移植术后不同合并症的发生率和发生时间,重点研究乙型病毒性肝炎(乙肝)复发与急性排斥反应的关系,肝癌再发/转移与急性排斥反应、肝癌大小及术前门静脉是否有癌栓之间的关系.结果:4例HBV相关性肝病患者术后合并急性排斥反应38例(70.4%;发生时间:-365 d)、慢性排斥反应1例(1.9%;发生时间:0.7个月)、胆道合并症24例(44.4%;发生时间:～940 d)、乙肝复发7例(13.O%;发生时间:～540 d)、丙型肝炎病毒感染3例(5.6%;发生时间:0 d、60 d和33个月)、巨细胞病毒感染8例(14.8%;发生时间:7～90 d)和移植肝肝癌再发/转移17例(31.5%;发生时间:～41个月).乙肝后肝硬化患者肝移植术后1年存活率为95%,术后3年存活率为85%;乙肝后肝癌患者肝移植术后1年存活率为67.6%,术后3年存活率为50%.乙肝复发病例和无乙肝复发病例中,急性排斥反应的人均发生次数分别为(0.86±1.46)次/人和(1.07±O.90)次/人,其中急性排斥反应活动指数(rejection activity index,RAI)≥4分的急性排斥反应人均发生次数分别为(O.29±O.49)次/人和(O.5±O.63)次/人,发生过≥3次急性排斥反应的患者分别占14.3%和10.6%,两者差异无统计学意义(P>0.05).移植肝肝癌再发/转移病例和无肝癌再发/转移病例中,急性排斥反应的人均发生次数分别为(1.12±O.93)次/人和(1.06±1.39)次/人,RAI>4分的急性排斥反应人均发生次数分别为(0.65±0.79)次/人和(O.65±1.06)次/人,发生过≥3次急性排斥反应的患者分别占5.9%和17.6%,两者差异无统计学意义.移植肝肝癌再发/转移病例和无肝癌再发/转移病例的术前肝癌直径为(6.72±3.40)cm和(3.55±2.17)cm(P=0.004 7),术前门静脉癌栓的发生率为68.75%和33.3%(P=0.006).结论:HBV相关性肝病患者肝移植术后乙肝复发和移植肝肝癌再发/转移与急性排斥反应无关,但移植肝肝癌再发/转移与术前癌肿较大和存在门静脉癌栓直接相关.

A clinicopathologic study on complications of orthotopic liver transplantation in 54 patients with chronic hepatitis B virus infection

OBJECTIVE:To study the complication incidence of 54 patients with chronic HBV infection following their orthotopic liver transplantation (OLT), and factors associated with HBV recurrence and hepatocellular carcinoma (HCC) recurrence or metastasis post-OLT . METHODS: The light-microscopic appearance of hepatic allograft biopsies in 54 patients with chronic HBV infection following OLT was examined. The related clinical data were analyzed. The incidence and occurrence time of post-OLT complications were studied. Furthermore, the relationship between recurrent type B viral hepatitis and acute rejection and the relationship among HCC recurrence/metastasis, acute rejection, the tumor diameter, and the portal vein invasion were particularly studied. RESULTS: The frequent complications of patients with chronic HBV infection following OLT were acute rejection 38(70.4%); occurrence time: 5-365 d], chronic rejection 1(1.9%); occurrence time: 10.7 months],bile duct complications 24(44.4%); occurrence time: 7-940 d], HBV recurrence 7(13.0%); occurrence time: 1-540 d], HCV infection 3(5.6%); occurrence time: 60 d, 60 d, 33 months], CMV infection 8(14.8%); occurrence time: 67-90 d], and HCC recurrence or metastasis 17(31.5%); occurrence time: 2-41 months]. At the end of 1 year post-OLT, 95% of patients with postjhepatitis B cirrhosis were alive; At the end of 3 years post-OLT, 85% of patients with post-hepatitis B cirrhosis were alive. However, at the end of 1 year post-OLT, 67.6% of patients with post-hepatitis B HCC were alive; At the end of 3 years post-OLT, 50% of patients with post-hepatitis B HCC were alive. The number of acute rejection episodes in patients with recurrent HBV infection and that without recurrent HBV infection was (0.86+/-1.46) time/patient and (1.07+/-0.90) time/patient respectively(P>0.05); the number of moderate acute rejection episodes(RAI>/=score 4) in patients with recurrent HBV infection and that without recurrent HBV infection was (0.29+/-0.49) time/patient and (0.50+/-0.63) time/patient(P>0.05); Incidence of patients with >/=3 episodes of acute rejection in patient with recurrent HBV infection and that without recurrent HBV infection was 14.3% and 10.6%(P>0.05). Furthermore, the number of acute rejection episodes in patients with HCC recurrence or metastasis and that without HCC recurrence or metastasis was (1.12+/-0.93) time/patient and (1.06+/-1.39) time/patient respectively(P>0.05); the number of moderate acute rejection episodes(RAI>/=score 4) in patients with HCC recurrence or metastasis and that without HCC recurrence or metastasis was (0.65+/-0.79) time/patient and (0.65+/-1.06) time/patient respectively(P>0.05); Incidence of patients with >/=3 episodes of acute rejection in patient with HCC recurrence or metastasis and that without HCC recurrence or metastasis was 5.9% and 17.6% respectively(P>0.05). The tumor diameter in patients with HCC recurrence or metastasis was (6.72+/-3.40)cm, however, that in patients without HCC recurrence or metastasis was (3.55+/-2.17)cm(P=0.004 7).The incidence of Portal vein invasion in patients with HCC recurrence or metastasis and that without HCC recurrence or metastasis was 68.75% and 33.3% respectively(P=0.006). CONCLUSION: There was no significant difference among HBV recurrence and acute rejection postjliver transplantation in patients with chronic HBV infection. There was no significant difference between HCC recurrence and acute rejection. The tumor diameter of patients with HCC recurrence or metastasis was significantly greater than that of no HCC recurrence or metastasis. The portal vein invasion of patients with HCC recurrence or metastasis was significantly frequent than that of no HCC recurrence or metastasis.