11例同种异体原位心脏移植的回顾性调查

[目的]评估同种异体原位心脏移植治疗终末期心脏疾病的疗效.[方法]对我院2003-2009年期间的11例终末期心脏疾病行心脏移植病人进行回顾性分析,包括术前准备、麻醉、心肌保护、体外循环、术式、术后监护治疗及随访情况,总结心脏移植的经验与教训.[结果]5例病人恢复良好,无并发症,生活自理,其中最长存活时间已达6年;6例死亡,其中术后急性右心衰2例,家中未规律服用免疫排斥药物2例,另外死于院外严重感染及慢性排斥反应各1例.[结论]同种异体原位心脏移植是治疗终末期心脏疾病的一种有效的方法,其中正确的供受体选择、良好的组织配型、有效的心肌保护、精湛的手术技术、严密的围术期管理是病人院内恢复的必备条件,培养自我保健意识及长期规范服用免疫排斥药物是院外长期存活的保障.     

健康教育在预防角膜移植并发症中的应用及效果评价

同种异体角膜移植术的实施为患者带来了复明的福音。但由于同种异体免疫排斥反应等手术并发症的存在,使部分成功的病例常因术后并发症而导致失败。术后并发症的发生与手术指征选择不当、手术操作的特点、术后感染、排斥反应、旧病复发等因素有关[1] 。临床观察发现,及时的健康教育在预防术后并发症的发生起关键作用。山东省聊城市人民医院自1 999年开展了角膜移植患者的全程健康教育,对患者进行了从入院到出院的全程健康教育,提高了患者自我保健能力,有效减少了并发症的发生,收到了良好的效果。对象与方法1 对象　1 0 0例住院患者,实验组5 …     

肝移植术后早期免疫原性的变化

目的探讨肝移植术后早期移植肝及宿主的供体免疫原性的动态变化。方法利用近交系大鼠,按Kamada的双套法行LEW→WF的原位全肝移植,将术后早期不同时期的移植肝或脾脏取出、分别注入移植后长期生存大鼠的腹腔内,观察能否诱导后者出现排斥反应。结果①移植12h后宿主的脾脏内存在最强的同种免疫刺激能力,2d后消失。②移植3d后的肝脏逐渐丧失了同种免疫刺激能力。结论移植肝和宿主的供体同种免疫原性在术后早期基本上消失了。     

肢体移植排斥反应中细胞凋亡及致死基因表达

目的探讨同种异体肢体移植急性排斥反应时细胞凋亡及致死基因Fas、Fas配体(FasL)表达的作用及其意义。方法建立近交系SD大鼠与wistar大鼠间原位异体肢体移植模型。实验观察组为异基因组，SD大鼠为供体，Wistar大鼠为受体；对照组为同基因移植组，在Wistar大鼠之间移植。分别进行左腿原位移植术。术后第1，3，5，7d分别取移植肢体组织进行病理学检查及电镜扫描，采用原位末端标记法(TUNEL)检测移植肢体中的凋亡细胞，免疫组化方法检测移植肢体中Fas、FasL表达的变化。结果实验组大鼠在术后发生由轻到重的急性排斥反应，对照组无明显排斥现象。实验组的移植物细胞凋亡数均明显高于对照组，凋亡细胞主要分布在血管内皮细胞及皮肤基底层细胞；术后第7d因严重排斥使小血管广泛栓塞。异基因肢体移植组的移植物中Fas／FasL表达增高，并与病理学检查及细胞凋亡程度一致。结论Fas、FasL介导的血管内皮细胞凋亡在大鼠异基因肢体移植急性排斥反应中发挥重要作用，可作为判断移植肢体预后及监测排斥反应的重要指标。     

小儿同种异体肝移植术后感染的监测和预防

目的 探讨小儿同种异体背驮式肝移植术后早期感染的监测和防治技术。方法 ２０００年３月３１日我科成功的进行了１例小儿同种异体背驮式肝移植。受体为１４岁男童,身高１３８ｃｍ,体重３４．５ｋｇ,患先天性Ｃａｒｌｏｌｉｓ病,曾行胆道手术,术前患儿胆汁性肝硬化,复发性胆管炎肝胆管结石,充血性脾肿大伴脾功亢进,低蛋白血症,肝功Ｃｈｉｌｄ Ｃ组,为终末期肝病,供体肝脏功能正常,大小适中,血型配型相符Ｏ型。在全麻     

CTLA-4Ig对大鼠同种异体肾移植移植肾功能的影响

目的研究CTLA-4Ig对大鼠同种异体肾移植移植肾功能的影响,为CTLA-4Ig作为一种新型的生物免疫抑制剂应用于临床提供实验依据。方法以LEW大鼠作为受体,BN大鼠作为供体,建立大鼠同种异体肾移植模型。受体LEW大鼠随机分四组,每组35只:(1)对照组:术中给予等体积生理盐水;(2)CTLA-4Ig低浓度组:术中给予CTLA-4Ig 1 mg/kg;(3)CTLA-4Ig中浓度组:术中给予CTLA-4Ig 10 mg/kg;(4)CTLA-4Ig高浓度组:术中给予CTLA-4Ig 20 mg/kg。给药途径为腹腔注射。分别于实验前、术后2小时、术后4小时、术后12小时、术后24小时、术后2天及术后3天收集血液标本,检测血浆CTLA-4Ig浓度及血清肌酐水平。结果对照组大鼠血浆中未检测到明显的CTLA-4Ig。给予不同浓度的CTLA-4Ig,大鼠血浆CTLA-4Ig浓度随之变化。给予CTLA-4Ig 1 mg/kg能有效保护同种异体肾移植的移植肾功能,保护作用随着浓度增加而增加,但CTLA-4Ig 10 mg/kg时保护作用已是最大,再加大给药浓度对移植肾功能保护没有意义。结论 CTLA-4Ig能减轻排斥反应,有效保护大鼠同种异体肾移植的移植肾功能。     

同种异体原位心脏移植3例临床总结

目的：总结3例同种异体原位心脏移植成功的处理经验，探讨供心保护、免疫抑制剂的应用及感染、预防急性排斥反应等问题。方法：2000年11月和2001年3月先后为终末期肥厚型心肌病、扩张型心肌病和先天性心脏病三尖瓣闭锁行肺动脉环缩术后等3例病人成功地施行了心脏移植手术。术后应用环孢霉素A（CSA）和甲基强的松龙、强的松龙等免疫抑制剂。结果：3例患者已分别生存半年和3个月，心功能正常，生活质量良好。结论：心脏移植、供心保护、吻合技术以及围手术期处理是手术成功的关键。     

肾移植术围手术期护理16例

目的 探讨肾移植术围术期有效的护理方法,提高肾移植术护理质量.方法 回顾性分析16例慢性肾功衰、尿毒症期的患者行同种异体肾移植术时的术前准备,术中早期保护、液体的管理及手术的配合,术后密切监测,预防急性排斥反应及其他并发症的发生.结果 全部患者术中平稳,无1例发生急性排斥反应及其他并发症,术后肾功能恢复良好.结论 充分的术前准备,认真的术前访视,良好的围术期护理,早期移植肾的保护,术后密切监测,是围手术期护理的关键.     

FK506对异体神经移植的影响

周围神经损伤后,异体神经移植对神经大段缺损的修复起着至关重要的作用。但免疫排斥反应仍是影响异体神经移植成败的关键所在,迄今为止已经有很多免疫抑制剂应用于临床。免疫抑制剂FK506能有效地抑制周围神经同种异体移植中的排斥反应。本综述从免疫抑制剂FK506的理化性质和作用机制及其对异体神经移植的影响因素入手,阐述免疫抑制剂FK506对神经恢复的促进作用,为FK506进一步的深入研究和临床应用提供理论依据。     

FK506对异体神经移植的影响

周围神经损伤后,异体神经移植对神经大段缺损的修复起着至关重要的作用。但免疫排斥反应仍是影响异体神经移植成败的关键所在,迄今为止已经有很多免疫抑制剂应用于临床。免疫抑制剂FK506能有效地抑制周围神经同种异体移植中的排斥反应。本综述从免疫抑制剂FK506的理化性质和作用机制及其对异体神经移植的影响因素入手,阐述免疫抑制剂FK506对神经恢复的促进作用,为FK506进一步的深入研究和临床应用提供理论依据。     

肝移植术后病原菌感染的临床分析

目的 分析肝移植术后细菌感染的流行病学资料及抗菌药物敏感性,为临床有效预防与控制感染,减少耐药菌株提供依据.方法 回顾性分析155例患者158次原位肝移植术后细菌学资料及其对抗菌药物的敏感性.结果 肝移植术后细菌性感染的发生率为25.9%,其主要病原菌分别为:凝固酶阴性葡萄球菌的分离率最高,96株占18.50%,其次为铜绿假单胞菌84株占16.18%,不动杆菌属73株占14.07%.结论 加强肝移植术后的抗菌药物选择、病原菌分离及其耐药性监测对于合理使用抗菌药物非常重要,依据病原学及抗菌药物敏感性资料合理选择抗菌药物控制感染,有助于减少新的耐药菌株的出现.     

Surgical aspects of pediatric liver transplantation. Living donor liver transplant program in Hungary

Because of the long waiting time for pediatric liver transplantation, new techniques of liver transplantation were invented. Split and living-donor related liver transplantation are common today and the Kaplan-Meier (3 years) overall survival is over 80%. By splitting the liver, two recipients can be transplanted. In general, the left lobe is used for the pediatric, the right lobe for the adult recipient. There are a lot of combinations depending on the donor and recipient weight. The accepted liver volume is approx. 1% of the recipient body weight. The results of the Hungarian pediatric program improve, 27 transplantations were done using 14 partial liver grafts and living donor program was started. Using strict protocols and improving surgical skills, the overall pediatric survival was over 80% in the last 5 years.     

彩超引导粗针穿刺活检在原位肝移植术后诊断排斥反应的价值

对原位肝移植术后患者98例用粗针(18G)穿刺活检:48例采用实时动态CDFI引导手动负压抽吸式活检法,50例采用灰阶超声(B-US)引导自动切割式活检枪法。并比较了两种活检方法的进针次数、并发症的发生率、成功率和病理诊断排斥反应的结果等。结果表明:原位肝移植术后采用实时动态彩色多普勒血流图引导18G手动负压抽吸式针活检取材量大,进针次数少并发症发生率低,优于普通灰阶超声引导18G自动切割式活检枪法。     

Liver transplantation with a living donor: the first 3 cases in Rotterdam

Liver transplantation with a part of the liver from a healthy living donor can be life saving for selected patients with end-stage liver failure. The experiences with the first 3 adult patients in the Netherlands were as follows. The first patient was a 56-year-old man with primary sclerosing cholangitis, who received half of the liver from his 53-year-old sister. Postoperatively, the donor developed a urinary tract infection, which was treated with antibiotics. The recipient developed fever and paralytic ileus 6 days after transplantation. Relaparotomy revealed minimal bile leakage from the cut surface of the liver, which was corrected with a suture. Three years after donation, both donor and recipient were doing well. The second patient was a 63-year-old man with hepatic cirrhosis due to hepatitis B, recurrent bleeding from varices, and hepatocellular carcinoma. The carcinoma was treated percutaneously with radiofrequency ablation. He was given a liver transplant from his 28-year-old son. The donor later developed transient ileus and mild liver function disorders. The recipient developed a bacterial infection of the ascites, which was treated with antibiotics, and later Candida-oesophagitis and a herpes simplex infection, which were also treated successfully. More than 2 years after donation and transplantation, both donor and recipient were in good condition. The third patient was a 42-year-old man with a chronic hepatitis B virus infection and 2 hepatocellular carcinomas. The donor was his 34-year-old sister-in-law. The recipient developed prolonged jaundice due to stenosis at the site of the bile duct anastomosis, for which a stent was placed. He was discharged in good condition but died 11 months later of cerebral metastases. One year after the procedure, the donor was doing well. The Rotterdam liver transplantation programme with living donors demonstrates that excellent results can be accomplished with minimal risk for the donor.     

Effectiveness and safety of immunization with live-attenuated and inactivated vaccines for pediatric liver transplantation recipients

BackgroundLiver transplantation recipients are at high risk for severe complications due to infections because of being treated with immunosuppressive drugs that affect the immune system. Vaccination for liver transplantation candidates is generally recommended before surgery, but the opportunities for vaccination prior to transplantation in pediatric candidates are often limited by severe disease conditions.MethodsThe participants in this study comprised 39 pediatric recipients of living donor liver transplantation performed between 2005 and 2013. Criteria for administering live-attenuated (measles, rubella, mumps, and varicella) and inactivated (hepatitis B, pertussis, and Japanese encephalitis) vaccines were as follows: (1) >1 year after transplantation; (2) no use of systemic steroids to treat acute rejection within the last 6 months; (3) serum trough concentration of tacrolimus <5 ng/mL; (4) no severe immunosuppression according to blood examinations; and (5) provision of written informed consent. Median age at transplantation was 17 months, and median period from transplantation to the beginning of immunization was 18 months.ResultsSeroprotection rates for measles, rubella, mumps, varicella, hepatitis B, pertussis, and Japanese encephalitis after post-transplant immunization were 44% (11/25), 70% (19/27), 48% (12/25), 32% (6/19), 83% (19/23), 87% (13/15), and 88% (7/8), respectively. Seroprotection rates for measles, rubella, mumps, and varicella after second vaccination for recipients with primary vaccine failure after first vaccination were 100% (8/8), 50% (1/2), 71% (5/7), and 50% (5/10), respectively. While four recipients contracted mumps and eight contracted varicella before immunization, one recipient developed varicella after immunization. No serious systemic adverse events were observed in vaccinated recipients.ConclusionsSeroprotection rates for measles, mumps, and varicella appeared low in children after the first post-transplantation vaccination. Immunizations with four live-attenuated and three inactivated vaccines were safe and effective for pediatric liver transplantation recipients who were not severely immunosuppressed.     

钆贝葡胺增强磁共振血管成像对肝移植术后血管并发症的诊断价值

目的：研究钆贝葡胺增强磁共振血管成像对肝移植术后血管并发症的诊断价值。方法：46例肝移植患者术后行MRI扫描;利用testbolus测出循环时间后行3D-FLASH扫描,获得各期血管图像。将MRA图像质量确定为5级,诊断血管并发症。结果：MRA对于血管的显示质量均较好。MRA发现肝动脉狭窄6例,肝动脉迂曲3例;门静脉狭窄12例,门静脉栓塞3例;肝静脉变窄4例,均经临床证实。结论：钆贝葡胺增强磁共振血管成像安全无创,对肝动脉、门静脉、肝静脉显示清楚,诊断血管并发症准确度高,有可能成为肝移植术后血管评价首选的影像学检查手段。     

不同营养方式对肝移植术后感染率的影响

目的 :对比不同营养方式下肝移植术后细菌、真菌感染率 ,与感染直接相关的病死率和感染部位分布等情况 ,寻找肝移植术后降低感染率方面更恰当的营养方式。　方法 :对 132例术前营养评估为中、重度营养不良的原位肝移植病人按时间段分为两组 ,第 1组 6 3例 ,术后实行全胃肠外营养 (TPN) 1周 ;第 2组 6 9例 ,术后第 2天起采取部分肠内营养 (EN)加肠外营养 (PN) ,再逐步向完全EN(TEN)过渡 ,比较两组病人细菌和真菌感染率、与感染直接相关的病死率和感染部位分布比例。　结果 :EN加PN组较TPN组病人肝移植术后真菌、细菌、肠道真菌和原发性血行细菌感染率均明显下降 (P <0 .0 5 ) ;EN加PN组与感染直接相关的病死率较TPN组有下降 ,但两组无显著差异(P >0 .0 5 )。　结论 :对于术前合并中、重度营养不良的病人 ,肝移植术后早期应用EN加PN ,再逐步向TEN过渡的方法在预防感染方面明显优于TPN。     

肝移植术后细菌感染病原学特征的研究

目的研究肝移植术后细菌感染的病原学特征,提供治疗指导。方法回顾性分析139例患者,141次原位肝移植术后细菌学资料。结果肝移植术后细菌感染率为29.4%,6例因感染死亡,与感染相关的死亡率4.3%;89.7%的细菌感染发生在术后1个月内;易感器官依次为腹腔、呼吸道和胆道,感染率分别为35.3%、26.4%、19.1%;共分离出菌株639株,其中革兰阴性(G-)杆菌占38.8%,革兰阳性(G )球菌占61.2%;最常见的G-杆菌依次为铜绿假单胞菌、鲍氏/溶血不动杆菌、大肠埃希菌、阴沟肠杆菌、肺炎克雷伯菌,最常见的G 球菌为屎肠球菌、溶血葡萄球菌、MRSE、MRSA、粪肠球菌。结论肝移植术后细菌感染是影响预后的重要因素;感染以高度耐药菌为主,应加强对移植前后病原学的监测;肝移植术后细菌感染部位与菌群有明显相关性。     

Combined antiviral treatment in a patient with recurrent chronic hepatitis C after liver transplantation

BACKGROUND: Hepatitis C virus infection persists after liver transplantation and causes recurrent liver injury in the majority of the patients. We report a case of orthotopic liver transplantation with more than five years survival despite the early recurrence of hepatitis C virus. CASE REPORT: A 49-year old woman underwent orthotopic liver transplantation because of liver cirrhosis following chronic hepatitis C virus infection. Twelve years before she received blood-transfusion. The chronic liver disease was diagnosed four years later. However, then it was thought to be a drug induced liver damage. After the liver transplantation hepatitis C chronic hepatitis recurred within one year. The serotype analysis (1b) proved the autoreinfection. The combined antiviral treatment (interferon plus ribavirin) resulted significant improvement. She was asymptomatic nearly for two years. The liver biopsy showed a significant histological improvement. However the virologic response and remission was transient. Four years after the transplantation recurrence occurred again. The liver biopsy proved cirrhosis. Antiviral therapy with pegylated interferon plus ribavirin was started but it had been stopped because of severe cytopenia. Lack of adequate antiviral treatment her condition became progressively worse. Finally, five years after the transplantation she died because of bilateral haemorrhagic ovarian necrosis and severe circulatory insufficiency thanks to the low albumin level. CONCLUSIONS: In the case of liver cirrhosis caused by hepatitis C virus the liver transplantation could prolongs the life with years. The presented case illustrate that the hepatitis C virus injures the transplanted liver by autoreinfection. However, the combined antiviral therapy could result sustained virologic response in these cases as well. Our patient survived five years thanks to the transplantation and the following antiviral therapy.