The Royal Free Sheila Sherlock Liver Centre and University Department of Surgery, Royal Free Hospital and UCL, London, UK.
J Hepatol. 2012 Apr;56(4):973-83. doi: 10.1016/j.jhep.2011.06.031. Epub 2011 Sep 29.
HCV related liver disease is the most common indication for liver transplantation. Recurrence of HCV infection is universal and has a substantial impact on patient and graft survival. Immunosuppression is a major factor responsible for the accelerated recurrence and compressed natural history of recurrent HCV infection. Accumulating experience has provided data to support certain strategies for immunosuppressive regimens. From the available evidence, more severe recurrence results from repeated bolus corticosteroid therapy and anti-lymphocyte antibodies used to treat rejection. Low dose and slow tapering of steroids are better than high dose maintenance and/or rapid tapering. Recent meta-analyses favour steroid-free regimens but these are complicated to interpret as the absence of steroids may simply represent less immunopotency. There is no difference in HCV recurrence between tacrolimus and cyclosporine regimens, but tacrolimus increases graft and patient survival in HCV transplanted patients. There may be a beneficial effect of maintenance azathioprine given for 6 months or longer. There is no conclusive evidence for benefit of mycophenolate and interleukin-2 receptor blockers. Few data are available for mTOR inhibitors. Better evidence is needed to establish the optimal immunosuppressive regimen for HCV recipients and more randomized trials should be performed.
丙型肝炎相关肝病是肝移植最常见的适应证。丙型肝炎病毒(HCV)感染的复发是普遍存在的，对患者和移植物的生存有重大影响。免疫抑制是导致 HCV 感染复发加速和自然史压缩的主要因素。积累的经验为免疫抑制方案提供了数据支持。现有证据表明，反复使用皮质类固醇冲击治疗和抗淋巴细胞抗体治疗排斥反应会导致更严重的复发。低剂量和缓慢减量的类固醇优于高剂量维持和/或快速减量。最近的荟萃分析支持无类固醇方案，但这些方案难以解释，因为没有类固醇可能只是代表免疫原性较低。他克莫司和环孢素方案在 HCV 复发方面没有差异，但他克莫司可增加 HCV 移植患者的移植物和患者存活率。给予 6 个月或更长时间的维持硫唑嘌呤可能有益。环磷酰胺和白细胞介素 2 受体阻滞剂的获益尚无定论。很少有关于 mTOR 抑制剂的数据。需要更多的随机试验来建立 HCV 受者的最佳免疫抑制方案，以获得更好的证据。
