Loinaz C, Lumbreras C, Moreno E, Colina F, Fuertes A, Gómez R, Jiménez C, González-Pinto I, García I, Rojas J, Bellorín C
Department of Surgery, Hospital 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain.
Hepatogastroenterology. 2001 Sep-Oct;48(41):1435-42.
BACKGROUND/AIMS: Hepatitis C-related liver disease is the main indication for liver transplantation in many centers. Viral RNA remains after transplantation in almost 100% of the patients, and more recent reports show a graft hepatitis rate of about 90%. The progression of this hepatitis seems to be quicker than in the nontransplant setting.
From June 1989 to October 2000, 197 adult patients had 213 for HCV-related liver disease at our institution. Basal immunosuppression consisted of a triple therapy with cyclosporine, azathioprine and steroids, or dual therapy with tacrolimus and steroids. None of the patients was treated with antivirals after liver transplantation.
Pure HCV-related cirrhosis was the indication for liver transplantation in 114 patients, another 14 with hepatocellular carcinoma, 8 associated metabolic diseases, 43 high alcohol intake, 4 hepatitis B, 5 cholestatic diseases, and 3 other diseases. Six patients out of the 197 transplanted in this period were already grafted before this time, and had their first retransplantation of the liver after 1989 (their first liver transplantation was done when HCV was not known). Sixteen additional retransplantation procedures were done in the period considered. Hepatitis was diagnosed in 84.3% of the grafts biopsied later than 90 days after liver transplantation (118/140), and in 92.9% if it was done after one year (92/99). Cirrhosis was diagnosed in 21 grafts at a mean time of 1004.7 days, 21.2% of the grafts biopsied after 1 year and 28.6% after 2 years. Nine grafts in 8 patients were diagnosed as fibrosing cholestatic hepatitis. Patient actuarial survival was 80.9%, 69.7%, 67.5% and 50.6% at 1, 3, 5 and 10 years. Liver failure and hepatoma recurrence were the cause of death in 42.4% of the patients. Actuarial graft survival was 75.2%, 64.9%, 63.5% and 48.6% at 1, 3, 5 and 10 years, and was significantly affected by Child stage (B vs. C, P = 0.004). When compared to 228 non-HCV- infected patients with chronic parenchymatous disease, these had an almost significantly better patient survival (P = 0.0577), but a nonsignificant difference in graft survival. Graft loss related to liver causes was 17.6% in HCV+ patients 14.6% in HCV- patients. Liver causes of death were 14.0% in HCV+ patients and 4.8% in HCV-patients (P = 0.002).
HCV infected liver transplantation recipients present very often graft hepatitis, which may progress to advanced stages in a quite short interval. Mid-term patient and graft survival is comparable to those of non-HCV recipients, but causes of death related directly to liver disease are more common in HCV+. This makes one think that long-term prognosis (more than 10 or 15 years) will be worse in HCV patients.
背景/目的：在许多中心，丙型肝炎相关肝病是肝移植的主要适应证。几乎100%的患者移植后病毒RNA仍持续存在，并且最近的报告显示移植肝肝炎发生率约为90%。这种肝炎的进展似乎比非移植情况下更快。
从1989年6月至2000年10月，在我们机构有197例成年患者因丙型肝炎相关肝病进行了213次肝移植。基础免疫抑制包括环孢素、硫唑嘌呤和类固醇的三联疗法，或他克莫司和类固醇的双联疗法。肝移植后没有患者接受抗病毒治疗。
114例患者因单纯丙型肝炎相关肝硬化接受肝移植，另外14例因肝细胞癌，8例伴有代谢性疾病，43例有大量饮酒史，4例有乙型肝炎，5例有胆汁淤积性疾病，3例有其他疾病。在此期间接受移植的197例患者中有6例在此之前已经接受过移植，并在1989年后进行了首次肝再次移植（他们的首次肝移植是在丙型肝炎未被认识时进行的）。在本研究期间还进行了另外16次再次移植手术。在肝移植后90天以后进行活检的移植物中，84.3%（118/140）被诊断为肝炎，如果是在1年后进行活检，则92.9%（92/99）被诊断为肝炎。21个移植物在平均1004.7天被诊断为肝硬化，占1年后进行活检移植物的21.2%，2年后进行活检移植物的28.6%。8例患者的9个移植物被诊断为纤维性胆汁淤积性肝炎。患者1年、3年、5年和10年的实际生存率分别为80.9%、69.7%、67.5%和50.6%。肝衰竭和肝癌复发是42.4%患者的死亡原因。移植物1年、3年、5年和10年的实际生存率分别为75.2%、64.9%、63.5%和48.6%，并且受Child分期显著影响（B期与C期相比，P = 0.004）。与228例非丙型肝炎感染的慢性实质性疾病患者相比，这些患者的患者生存率几乎显著更好（P = 0.0577），但移植物生存率无显著差异。丙型肝炎病毒阳性患者中与肝脏原因相关的移植物丢失率为17.6%，丙型肝炎病毒阴性患者为14.6%。丙型肝炎病毒阳性患者肝脏原因导致的死亡率为14.0%，丙型肝炎病毒阴性患者为4.8%（P = 0.002）。
丙型肝炎病毒感染的肝移植受者经常出现移植肝肝炎，其可能在相当短的时间内进展至晚期。中期患者和移植物生存率与非丙型肝炎病毒受者相当，但直接与肝脏疾病相关的死亡原因在丙型肝炎病毒阳性患者中更常见。这使人认为丙型肝炎病毒患者的长期预后（超过10年或15年）将更差。
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