Gane Edward, Pilmore Helen
New Zealand Liver Transplant Unit, Auckland Hospital, New Zealand.
Transplantation. 2002 Aug 27;74(4):427-37. doi: 10.1097/00007890-200208270-00001.
Hepatitis C virus (HCV) infection is present in 2-50% of renal transplant recipients and patients receiving hemodialysis. Renal transplantation confers an overall survival benefit in HCV positive (HCV+) hemodialysis patients, with similar 5-year patient and graft survival to those without HCV infection. However, longer-term studies have reported increased liver-related mortality in HCV-infected recipients. Unfortunately, attempts to eradicate HCV infection before transplant have been disappointing. Interferon is poorly tolerated in-patients with end-stage renal disease and ribavirin is contraindicated because reduced renal clearance results in severe hemolysis. Antiviral therapy following renal transplantation is also poorly tolerated, because of interferon-induced rejection and graft loss. Although the prevalence of hepatitis B virus (HBV) infection has declined in hemodialysis patients and renal transplant recipients since the introduction of routine vaccination and other infection control measures, it remains high within countries with endemic HBV infection (especially Asia-Pacific and Africa). Renal transplantation is associated with reduced survival in HBsAg+ hemodialysis patients. Unlike interferon, lamivudine is a safe and effective antiviral HBV treatment both before and after renal transplantation. Lamivudine therapy commenced at transplantation should prevent early posttransplant reactivation and subsequent progression to cirrhosis and late liver failure. This preemptive therapy should also eradicate early liver failure from fibrosing cholestatic hepatitis. Because cessation of treatment may lead to severe lamivudine-withdrawal hepatitis, most patients require long-term therapy. The development of lamivudine-resistance will be accelerated by immunosuppression and may result in severe hepatitis flares with decompensation. Regular monitoring with liver function tests and HBV DNA measurements should enable early detection and rescue with adefovir. Chronic HCV and HBV infections are important causes of morbidity and mortality in renal transplant recipients. The best predictor for liver mortality is advanced liver disease at the time of transplant, and liver biopsy should be considered in all potential HBsAg+ or HCV+ renal transplant candidates without clinical or radiologic evidence of cirrhosis. Established cirrhosis with active viral infection should be considered a relative contraindication to isolated renal transplantation.
2%至50%的肾移植受者和接受血液透析的患者存在丙型肝炎病毒（HCV）感染。肾移植对HCV阳性（HCV+）的血液透析患者具有总体生存益处，其5年患者生存率和移植物生存率与未感染HCV的患者相似。然而，长期研究报告称，HCV感染的受者肝脏相关死亡率有所增加。遗憾的是，移植前根除HCV感染的尝试令人失望。终末期肾病患者对干扰素耐受性差，而利巴韦林因肾清除率降低会导致严重溶血而被禁用。肾移植后的抗病毒治疗耐受性也很差，因为干扰素会引发排斥反应和移植物丢失。尽管自常规疫苗接种和其他感染控制措施实施以来，血液透析患者和肾移植受者中乙型肝炎病毒（HBV）感染的患病率有所下降，但在HBV感染流行的国家（尤其是亚太地区和非洲），该患病率仍然很高。肾移植与HBsAg+血液透析患者生存率降低有关。与干扰素不同，拉米夫定在肾移植前后都是一种安全有效的抗HBV治疗药物。移植时开始的拉米夫定治疗应可预防移植后早期再激活以及随后发展为肝硬化和晚期肝衰竭。这种抢先治疗还应能根除纤维性胆汁淤积性肝炎导致的早期肝衰竭。由于停止治疗可能导致严重的拉米夫定撤药后肝炎，大多数患者需要长期治疗。免疫抑制会加速拉米夫定耐药性的产生，并可能导致严重的肝炎发作伴失代偿。定期进行肝功能检查和HBV DNA检测应能实现早期检测，并使用阿德福韦进行挽救治疗。慢性HCV和HBV感染是肾移植受者发病和死亡的重要原因。肝死亡的最佳预测指标是移植时的晚期肝病，对于所有潜在的HBsAg+或HCV+肾移植候选者，若没有临床或影像学肝硬化证据，均应考虑进行肝活检。已确诊的肝硬化合并活动性病毒感染应被视为孤立肾移植的相对禁忌证。
