《国际肝病》：二次肝移植病人的生存率一般低于一次移植，请问若想提高其生存率，需注意哪些因素？
Prof. Burra: I believe we need to work very hard after the first transplant targeting patient risk factors with the aim of reducing the need for retransplantation. These involve ensuring that there is a good match between donor and recipient by avoiding using a liver from an older donor and transplanting that organ into an HCV positive patient In addition we should offer strong advice and recommendations for patients to abstain from alcohol consumption after transplantation and educate patients on particular lifestyle choices such as increased exercise to prevent weight gain. Collectively these will reduce the risk of metabolic syndrome development and diabetes which increases the rate of liver fibrosis progression after surgery.
Burra教授：为了减少二次移植的需求，首次移植后还需要针对病人风险因素进行大量工作。包括避免应用高龄供者的肝脏及移植给HCV阳性病人，以确保供受体间较好的匹配。此外，应积极建议病人移植后戒酒，指导病人选择生活方式，如多加锻炼避免体重增加。这些措施可以减少发生代谢综合征和糖尿病的风险，而这二种疾病都可能增加术后肝纤维化进展的发生率。
Hepatology Digest：SVR (Sustained Virologic Response) rates are lower in liver transplanted patients compared to patients who have not undergone a transplant. What can we do to increase the SVR rates in these patients?
《国际肝病》：与未行移植的病人相比，肝移植后病人的SVR率（持续病毒学应答）较低。请问怎样提高这类病人的SVR率？
Prof. Burra：We have seen positive results if we separate patients who have HCV genotypes 1 and 4 from those who have 2 and 3. We have also seen encouraging results using pegylated-interferon and ribavirin in selected transplanted patients. Having said that we must remember that this therapy is being administrated in the presence of immunosuppressive drugs which may interfere with the effect of antivirals. Cyclosporin itself has an antiviral effect， and therefore it might be feasible to use cyclosporine in combination with pegylated-interferon and ribavirin. However we still need randomized studies and results that can confirm this as well as comparing tacrolimus and cyclosporin in terms of their effect on SVR and fibrosis progression.
Burra教授：将HCV基因1、4型的病人从基因2、3型中区分离出来，可以看到SVR率明显提高。或者移植后病人联合应用长效干扰素和利巴韦林，SVR率也令人振奋。要注意的是，上述治疗是在应用环孢霉素等免疫抑制剂的同时给予的，环孢霉素本身就有抗病毒作用。因此，环孢霉素与长效干扰素-利巴韦林联合应用是可行的。但仍然需要随机试验证实这一联合方案具有与他克莫司和环孢霉素的肝纤维化和SVR率类似的效果。
Hepatology Digest: Would you ever recommend reducing the dosage of immunosuppressive drugs in patients undergoing HCV therapy?
《国际肝病》：对正进行HCV治疗的病人您建议减少免疫抑制剂用量吗？
Prof. Burra: I would be very careful about doing that because we stand the risk of having unexpected immune mediated reactions. This is especially the case if we reduce these drugs during antiviral therapy which may cause the immune system to act very aggressively on the liver. I would maintain the dosage of immunosuppressives in particular for those patients undergoing antiviral therapy.
Burra教授：我对调整免疫抑制剂用量非常谨慎。因为减量可能要面临不可预料的免疫介导反应，尤其是抗病毒期间减少免疫抑制剂用量，更可能对移植肝造成非常严重的免疫损伤。所以我倾向于不改变剂量，尤其对正进行抗病毒治疗的病人。
Hepatology Digest: Are there any predetermining factors that could guide a clinician on a patient’s risk of HCV recurrence after transplantation?
《国际肝病》：有没有预测因子可以指导医生判断肝移植后HCV复发的风险？
Prof. Burra：By putting together the information that we have from the recipient， patient’s viral load， donor and other risk factors we have this answer. Concerning retransplantation I think we should try to avoid this for patients over the age of 60 and try to avoid the use of organs from donors at this age. In addition I would also try to avoid retransplantation in those patients who have rapid elevated bilirubin levels a few months after the first transplant as well as those entering the early stages of cholestatic liver disease because we know the probability of survival is definitely lower in those cases.
Burra教授：综合考虑受体、病人的病毒载量、供体和其他风险因素可以作出判断。关于二次移植，我认为应该避免对大于60岁的病人进行二次移植，同时避免采用年龄大于60岁的供肝。此外，还应该注意避免对首次移植后数月血胆红素水平即很快增高，以及胆汁淤积性肝病早期病人进行二次移植，因为已经明确这类病人的生存率是非常低的。
