Samuel D, Muller R, Alexander G, Fassati L, Ducot B, Benhamou J P, Bismuth H
Hepatobiliary Surgery and Liver Transplantation Research Unit, Paul Brousse Hospital, Villejuif, France.
N Engl J Med. 1993 Dec 16;329(25):1842-7. doi: 10.1056/NEJM199312163292503.
The role of liver transplantation in patients positive for the hepatitis B surface antigen (HBsAg) is controversial because of the high rate of recurrent hepatitis B virus (HBV) infection. It has not been determined whether this risk is greater for certain patients and whether the administration of anti-hepatitis B surface antigen (anti-HBs) immune globulin is beneficial.
We conducted a retrospective study at 17 European centers of 372 consecutive HBsAg-positive patients who underwent liver transplantation between 1977 and 1990. Recurrence of HBV infection was defined as the reappearance of HBsAg in serum.
For all 334 patients with follow-up data, the mean (+/- SE) three-year actuarial risk of recurrence of HBV was 50 +/- 3 percent. The risk was 67 +/- 4 percent among 163 patients with HBV-related cirrhosis, 32 +/- 5 percent among 110 patients with cirrhosis related to hepatitis delta virus, 40 +/- 16 percent among 14 patients with fulminant hepatitis delta infection, and 17 +/- 7 percent among 39 patients with fulminant HBV infection (P < 0.001). Among the patients with HBV-related cirrhosis, the risk of HBV recurrence was greatest (83 +/- 6 percent) in those who were seropositive for HBV DNA at the transplantation and lowest (58 +/- 7 percent) in those with neither HBV DNA nor hepatitis B e antigen detectable in serum. With respect to the use of passive prophylaxis with anti-HBs immune globulin, the risk of HBV recurrence was 75 +/- 6 percent among the 67 patients given no immunoprophylaxis, 74 +/- 5 percent among the 83 treated for two months, and 36 +/- 4 percent among the 209 treated for six months or longer (P < 0.001). In a multivariate analysis the predictors of a lower risk of HBV recurrence were the long-term administration of the immune globulin, hepatitis delta virus superinfection, and acute liver disease. For the entire study cohort, survival was 75 percent at one year and 63 percent at three years, but for those in whom HBV infection recurred, survival was 68 percent at one year and 44 percent at three years.
In this retrospective study of HBsAg-positive patients, liver transplantation had better results in those who had fulminant hepatitis or delta virus superinfection. An absence of viral replication at the time of transplantation and long-term immunoprophylaxis were associated with a reduced risk of recurrent HBV infection and reduced mortality.
由于乙型肝炎病毒（HBV）感染复发率高，肝移植在乙肝表面抗原（HBsAg）阳性患者中的作用存在争议。尚未确定某些患者的这种风险是否更高，以及给予抗乙肝表面抗原（抗-HBs）免疫球蛋白是否有益。
我们在17个欧洲中心对1977年至1990年间连续接受肝移植的372例HBsAg阳性患者进行了一项回顾性研究。HBV感染复发定义为血清中HBsAg再次出现。
在所有334例有随访数据的患者中，HBV复发的平均（±标准误）三年精算风险为50±3%。在163例HBV相关肝硬化患者中，风险为67±4%；在110例丁型肝炎病毒相关肝硬化患者中，风险为32±5%；在14例暴发性丁型肝炎感染患者中，风险为40±16%；在39例暴发性HBV感染患者中，风险为17±7%（P<0.001）。在HBV相关肝硬化患者中，移植时HBV DNA血清学阳性者HBV复发风险最高（83±6%），血清中未检测到HBV DNA和乙肝e抗原者风险最低（58±7%）。关于使用抗-HBs免疫球蛋白进行被动预防，67例未接受免疫预防的患者中HBV复发风险为75±6%，83例接受两个月治疗的患者中为74±5%，209例接受六个月或更长时间治疗的患者中为36±4%（P<0.001）。在多变量分析中，HBV复发风险较低的预测因素是免疫球蛋白的长期使用、丁型肝炎病毒重叠感染和急性肝病。对于整个研究队列，一年生存率为75%，三年生存率为63%，但HBV感染复发者一年生存率为68%，三年生存率为44%。
在这项对HBsAg阳性患者的回顾性研究中，肝移植在暴发性肝炎或丁型肝炎病毒重叠感染患者中效果更好。移植时无病毒复制和长期免疫预防与HBV感染复发风险降低及死亡率降低相关。
