再次肝移植

在首次移植失败后,再次肝脏移植是挽救移植肝失功受体病人生命的唯一手段。随着肝移植受体数量的积累,再次肝移植的数量也必将越来越多,再次肝移植越来越成为一个令人关注的问题。近年来随着供体紧缺和新型免疫抑制剂的研发,再次肝移植的适应证发生了明显变化,而总的再移植发生率逐步下降。严格评估再次肝移植术前受体的状况,充分考虑再次肝移植的危险因素对提高再次肝移植术后的生存率尤为重要。手术时机和适应证的正确把握、手术技巧的提高是再次肝移植手术成功和提高术后生存率的关键。     

再次肝移植10例临床分析

目的总结再次肝移植的临床经验。方法回顾性分析我中心自2003年5月至2006年12月间实施的10例再次肝移植患者的临床资料并进行随访,对再次移植的指征、手术时机、手术方式及预后进行讨论。结果在连续实施的315例同种异体原位肝移植中共有10例接受了再次移植．再次移植率为3．17％。再次移植指征分别为胆道并发症4例（40％）,原发病复发4例（40％）,其中包括肝癌复发2例（20％）,乙肝复发1例（10％）,肝硬化复发1例（10％）,移植肝原发性无功能1例（10％）．肝动脉血栓形成1例（10％）。10例患者中有3例死亡,其中2例死于全身严重的感染伴多器官功能衰竭,1例死于肝癌复发转移。其余7例患者均痊愈出院．随访至今已存活10～28月．肝功能及一般状况良好。结论合理选择再次移植的指征,把握合适的手术时机,建立完善的预后评估模型是提高再次肝移植患者存活率的关键。     

再次肝移植的肝动脉重建方法探讨(附15例报告)

目的探讨再次肝移植肝动脉重建的方法。方法回顾15例再次肝移植的临床资料,分析肝动脉重建的不同方式。其中供体动脉与受体肝固有动脉与胃十二指肠动脉汇合部吻合重建4例(26.7%),与受体肝总动脉吻合重建4例(26.7%),与受体脾动脉吻合重建4例(26.7%),与受体腹主动脉架桥吻合重建3例(19.9%)。结果15例再次肝移植患者中11例(73.3%)术后顺利恢复,生存期1~22个月,中位生存期9个月。4例(26.7%)于术后早期死于感染性休克、多器官功能衰竭、急性心肌梗塞和颅内出血等并发症。所有患者术后肝动脉血流均正常,未出现血栓形成、肝动脉狭窄或假性动脉瘤等并发症。结论再次肝移植肝动脉重建情况复杂,方式多样,根据供、受体肝动脉解剖的特点和首次移植时肝动脉的重建情况灵活选择适当的重建方式并进行细致的吻合,是再次肝移植肝动脉重建成功的关键。     

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目的总结再次肝移植病人围手术期临床特点和管理经验。方法回顾分析中山大学附属第三医院肝移植中心2004年1月至2006年12月期间施行的34例再次肝移植受者临床资料。结果再次肝移植的原因分别为移植术后胆道并发症(18例)、移植术后肝癌复发(6例)、肝炎复发(6例)以及肝动脉并发症(4例)。34例均采用附加腔静脉整形的改良背驮式肝移植技术。全组无手术死亡。院内死亡9例(26.5%),明显高于首次肝移植的病死率(6.9%,46/671)(P<0.05)。死亡原因中感染占55.6%(5/9)。再次肝移植组术前感染率为32.4%(11/34),首次肝移植组为10.7%(72/671),两组间差异有显著性意义(P<0.05)。再次肝移植组术后感染率为61.8%(21/34),首次肝移植组为46.3%(311/671),两组相比差异无显著性意义(P>0.05)。结论感染是再移植的主要死亡原因,围手术期有效的抗感染治疗和针对再次肝移植特点的个体化免疫抑制方案可以提高再次肝移植的成功率。     

Results after liver retransplantation in a group of 50 regrafted patients: two different concepts of elective versus emergency retransplantation

Abstract. Liver retransplantation remains the only alternative therapy for irreversible graft failure. Previous studies have demonstrated lower survival rates for liver retransplantation than for primary grafts. After reviewing our clinical experience with 55 retransplantations out of 365 liver transplants, we found that the risk and results depend on the surrounding circumstances. Elective retransplantation was shown to be as safe as the first liver transplantation, while emergency retransplantation yielded significantly higher morbidity and mortality rates.     

Results after liver retransplantation in a group of 50 regrafted patients: two different concepts of elective versus emergency retransplantation

Liver retransplantation remains the only alternative therapy for irreversible graft failure. Previous studies have demonstrated lower survival rates for liver retransplantation than for primary grafts. After reviewing our clinical experience with 55 retransplantations out of 365 liver transplants, we found that the risk and results depend on the surrounding circumstances. Elective retransplantation was shown to be as safe as the first liver transplantation, while emergency retransplantation yielded significantly higher morbidity and mortality rates.     

Comparison of short- and long-term outcomes after early versus late liver retransplantation: a single-center experience

Background

As the survival of patients after liver transplantation (LT) improves, the requirement of liver retransplantation (reLT) for late graft failure has grown. Although some have reported that the short-term outcome of late reLT was comparable with that of early reLT, it remains unknown whether long-term survival of late reLT is inferior to that of early reLT patients.

Materials and methods

We reviewed early (<6 mo after primary LT) and late (≥6 mo after primary LT) reLT cases performed between January 2000 and December 2010.

Results

Sixteen early and 32 late reLT cases were analyzed. There was no significant difference regarding the number of units of red blood cells transfused during the transplantation between the groups, whereas operative time was significantly longer in the late reLT cases. Graft loss within 3 mo after early and late reLT was 18.6% and 15.6%, respectively. Patient and graft survival rates after 1, 3, 5, and 10 y in the late reLT group were 80.6%, 73.3%, 73.3%, and 67.7% and 80.7%, 69.1%, 63.3%, and 54.3%, respectively, whereas those in the early reLT group were 75.0%, 75.0%, 64.3%, and 64.3% and 81.3%, 75.0%, 64.3%, and 32.1%, respectively. There was no significant difference in patient or graft survival rates between the groups (P = 0.91 and 0.91, respectively).

Conclusions

Acceptable short- and long-term survival were provided in early and late reLT. The time between the primary LT and reLT does not seem to play significant role in the prognosis of reLT in the long term.     

Renal retransplantation in patients with HLA-antibodies

The results of 92 consecutive renal retransplantations, performed during a 5-year period in recipients with HLA-antibodies, were retrospectively analysed. The actuarial 1-year graft survival (1-y GS) was 65% for all retransplantations, as compared with 63% for first grafts in sensitized recipients. For the second (n = 56), third (n = 24) and fourth-fifth (n = 12) grafts 1-y GS was 64%, 71% and 58%, respectively. Acute rejection was the major cause of graft loss (45%). Recipients with > 3 years GS of the preceding transplant had significantly better GS at retransplantation. Also, grafts with no HLA mismatches had significantly prolonged GS. One-y GS was 78% when PRA (panel reacting antibody) was less than 50%, and 60% when PRA was more than 50%. A benefit of repeated mismatches was demonstrated in the subgroup with PRA < 50%, in contrast to recipients with PRA > 50%, suggesting that, in some patients, an absence of antibody response against certain antigens might be used as a basis for future deliberate mismatching.     

An outcome comparison between primary liver transplantation and retransplantation based on the pretransplant MELD score

Survival after liver retransplantation (RLTX) is worse than after primary liver transplantation (LTX). We studied retrospectively the 2-year outcome in 44 patients who received RLTX more than 30 days after the primary transplant and in 669 after LTX performed between December 1993 and October 1999, focusing on the relation between the model for end-stage liver disease (MELD) score immediately pretransplant and post-transplant survival. A 2-year survival for RLTX was inferior to LTX (65.9% vs. 82.9%, P < or = 0.01). This difference was greatest with MELD scores < 25; survival within 2 years remained 11.3-18.2% less for RLTX than for LTX (6 months, P = 0.002; 12 months, P = 0.029, 24 months, P = 0.123). Mortality was mainly related to early vascular complications and sepsis. Two-year survival after RLTX was 81.8% if RLTX occurred < 2 years after LTX and 50% if the interval between LTX and RLTX was > 2 years (P < 0.05). MELD scores were similar in 2-year survivors and nonsurvivors after late RLTX (P = 0.82). Late RLTX is marked by poor survival regardless of the pretransplant MELD score. The MELD-based allocation system may not benefit patients who undergo retransplantation.     

Excellent liver retransplantation outcomes in hepatitis C‐infected recipients

Survival outcomes for liver retransplantation (LRTx) after graft loss in HCV patients (HCV‐LRTx) are generally considered inferior to those after non‐HCV‐LRTx. Between January 1, 2005 and June 30, 2011, our center performed 663 LTx, including 116 (17.5%) LRTx, 41 (35.3%) of which were more than 90 d after the LTx. Twenty‐nine (70.7%) LRTx were performed in HCV antibody–positive individuals. We compared patient demographics, baseline characteristics and outcomes of our HCV‐LRTx group with the HCV‐LRTx patients from the most recent OPTN database covering the same time period. Our Kaplan–Meier HCV‐LRTx one‐, three‐, and five‐yr HCV‐LRTx patient survival rates were 86.2%, 79.0%, and 72.4%, respectively compared with the OPTN one‐, three‐, and five‐yr HCV‐LRTx survival rates of 73.3%, 59.0%, and 51.3% respectively. Likewise, our graft survival rates were higher than OPTN rates at all time points studied. We performed a higher percentage of HCV‐LRTx as simultaneous liver/kidney transplants (SLK) (37.9% vs. 21.8%) and recorded shorter warm (30 ± 4 vs. 45 ± 23 min) and cold ischemic times (5:44 ± 1:53 vs. 7:36 ± 3:12 h:min). Conclusion: In our experience, HCV‐LRTx patient and graft survival rates are comparable to LTx survival rates and are higher than the rates described by OPTN.     

再次肝移植治疗移植肝失功能22例报告

目的 总结再次肝移植治疗移植肝失功能的临床经验。方法 回顾分析2004年1月至2006年6月期间中山大学附属第三医院施行22例再次肝移植受者的临床资料，结合文献加以讨论。再次肝移植的原因分别为移植术后胆道并发症（12例）、移植术后肝癌复发（4例）、肝动脉栓塞（2例）、肝动脉狭窄（2例）以及乙肝复发（2例）。再次移植率为3．62％，供肝植入均采用改良背驮式肝移植技术。结果 全组无手术死亡，8例随访至今分别存活21、14、8、3个月各1例，12、1个月各2例；14例存活2周到28个月不等。首次肝移植术后8～30d行再次肝移植病人围手术期病死率最高，为66．7％；1年内死亡10例，主要死亡原因为感染（60％）。结论 再次肝移植是移植肝失功能的惟一有效的治疗方法，正确掌握手术时机及适应证，钻研手术技巧，合理的个体化免疫抑制方案以及围手术期有效的抗感染治疗是提高再次肝移植病人存活率的关键。     

Kidney retransplantation from HLA‐incompatible living donors: A single‐center study of 3rd/4th transplants

Background

The demand for kidney retransplantation following graft failure is rising. Repeat transplantation is often associated with poorer outcomes due to both immunological and surgical challenges. The aim of this study was to compare surgical and functional outcomes of kidney retransplantation in recipients that had previously had at least two kidney transplants with a focus on those with antibody incompatibility.

Methods

We analyzed 66 patients who underwent renal transplantation at a single center between 2003 and 2011. Consecutive patients receiving their 3rd or 4th kidney were case‐matched with an equal number of 1st and 2nd transplants.

Results

Twenty‐two 3rd and 4th kidney transplants were matched with 22 first and 22 seconds transplants. Operative times and length of stay were equivalent between the subgroups. Surgical complication rates were similar in all groups (22.7% in 1st and 2nd transplants, and 27.2% in 3rd/4th transplants). There was no significant difference in patient or graft survival over 5 years. Graft function was similar between transplant groups at 1, 3, and 5 years.

Conclusions

Third and fourth kidney transplants can be performed safely with similar outcomes to 1st and 2nd transplants. Kidney retransplantation from antibody‐incompatible donors may be appropriate for highly sensitized patients.     

肝癌复发与未复发患者再次肝移植的预后分析

目的 探讨肝癌复发与未复发患者再次肝移植的效果.方法 初次肝移植时原发疾病为肝癌(病理诊断)、移植后因各种原因需行再次肝移植者65例(肝癌组),分析其进行再次肝移植的原因以及再次肝移植后的并发症发生情况和预后,并于同期因肝脏良性疾病施行肝移植、移植后因各种原因需行再次肝移植者66例(非肝癌组)进行比较.结果 肝癌组初次肝移植后有11例(16.9％,11/65)因肝癌复发而行再次肝移植,非肝癌组无因肝癌而行再次移植者,两组比较,差异有统计学意义(P＜0.01);非肝癌组初次肝移植后有11例(16.7％0,11/66)因血管并发症而进行再次肝移植,高于肝癌组(4.6％,3/65),差异有统计学意义(P＜0.05).肝癌组初次肝移植后肝癌复发者11例,其中10例(90.9％,10/11)在再次肝移植后因肝癌复发而死亡;肝癌组初次肝移植后肝癌未复发者54例,其中7例(13.0％,7/54)在再次肝移植后肝癌复发,明显低于复发者(P＜0.01),其移植肝5年累积存活率为51.0％,与非肝癌组(51.8％)差异很小(P＞0.05).结论 原发病为肝癌者初次肝移植后因肿瘤复发而行再次肝移植,其预后不佳;而因非肿瘤复发因素而行再次肝移植时,其再次肝移植的效果与因良性疾病而行肝移植者相近,不应受其原发疾病为肝癌的影响.     

Pancreas transplant outcomes for United States (US) and non-US cases as reported to the United Network for Organ Sharing (UNOS) and the International Pancreas Transplant Registry (IPTR) as of June 2004

As of December 31, 2004, more than 23,000 pancreas transplant had been reported to the IPTR, >17,000 in the US and almost 6000 from outside the US. An analysis of US pancreas transplants performed between 1988 and 2003 showed a progressive improvement in outcome, with pancreas transplant graft survival rates (GSRs) going from 75% at 1 yr for 1988/1989 to 85% for 2002/2003 simultaneous pancreas-kidney (SPK) cases, from 55 to 78% for pancreas after kidney (PAK) cases, and from 45 to 77% for pancreas transplants alone (PTA) cases. The improvements were due both to decreases in technical failure (TF) rates (from 12 to 6% in SPK, 13-8% in PAK, and 24-7% in PTA) and immunological failure rates (going from 7 to 2% for SPK, from 28 to 7% for PAK, and from 38 to 8% for PTA cases). These results are even more impressive under the aspect that during the same time the rate of potential risk factors increased and the duct management techniques changed from bladder to enteric drainage. The improvement in outcome allowed also an increase in the number of solitary pancreas transplants from initially 12% to now 35%. Contemporary primary deceased donor pancreas transplant outcomes were calculated separately for 2000-2004 US and non-US cases. The US patient survival rates at 1 yr were >95% in each recipient category, with 1 yr primary pancreas GSRs of 85% for SPK, 78% for PAK, and 76% for PTA (p < 0.0001). The immunological graft failure rates for 2000-2004 technically successful (TS) SPK, PAK, and PTA cases were 2, 8, and 10% at 1 yr (p = 0.0001). In the majority of all transplants ED was used for duct management (81% of SPK, 67% of PAK, and 56% for PTA cases). Of the ED transplants, venous drainage via the portal system was used for 20% of SPK, 23% of PAK, and 35% of PTA cases. Duct management technique did not have a significant impact on overall pancreas graft function in the univariate or the multivariate model. The outcomes of ED and BD transplants are comparable with 85 vs. 87% at 1 yr for SPK, 77 vs. 80% for PAK, and 72 vs. 79% for PTA. The overall TF rate was higher in ED pancreas transplants but this difference did reach significance only in SPK. In addition, in technically successful PTA the immunological graft loss rate was higher in ED vs. BD transplants (15 vs. 5% at 1 yr). The different vascular management techniques did not seem to have an impact on the outcome of the pancreas transplants. Kidney GSRs were not significantly different for ED vs. BD SPK cases, 93 and 91% at 1 yr (p = 0.24). The overall conversion rate from BD to ED was 9% at 1 yr and 17% at 3 yr post-transplant. The most influential factor for patient survival in SPK and PAK in the multivariate and the univariate models was the status of the transplanted organ. The hazard ratio (HR) for a failed kidney was 14.99 in SPK and 9.17 in PAK (p = 0.0001). The HR for a failed pancreas graft was 3.51 in SPK and 4.17 for PAK (p = 0.0001). In PTA a failed pancreas graft did not have a direct impact on patient survival. SPK and PAK patients older than 44 yr at the time of transplants also showed an increased mortality risk, but at the same time the risk of immunological graft loss was significantly decreased for those patients. TAC&MMF remained the dominant maintenance immunosuppressant for 2000-2004 US cases (approximately two-third) in all three categories and with this regime 1-year GSRs were > or =80% in all three recipient categories. The results were comparable (> or =83% 1-year GSR) for patients (approximately 10%) treated with Sirolimus (SIR) under various protocols. In regard to non-US pancreas transplants, even for 2000-2004 the overwhelming majority continued to be in the SPK category (91%), with 1-year patient, kidney and pancreas survival rates of 94, 92, and 87%. Solitary transplants are still very rarely done outside the US. Non-US PAK GSR at 1 yr was 85%, non-US PTA GSR at 1 yr was 76%. In summary, with the new advancements in immunosuppression and changes in surgical techniques the outcomes in patient survival and pancreas transplant graft function continue to improve even with an increasing proportion of high risk patients in all three categories.     

The Liver Retransplantation Risk Score: a prognostic model for survival after adult liver retransplantation

High-risk combinations of recipient and graft characteristics are poorly defined for liver retransplantation (reLT) in the current era. We aimed to develop a risk model for survival after reLT using data from the European Liver Transplantation Registry, followed by internal and external validation. From 2006 to 2016, 85 067 liver transplants were recorded, including 5581 reLTs (6.6%). The final model included seven predictors of graft survival: recipient age, model for end-stage liver disease score, indication for reLT, recipient hospitalization, time between primary liver transplantation and reLT, donor age, and cold ischemia time. By assigning points to each variable in proportion to their hazard ratio, a simplified risk score was created ranging 0–10. Low-risk (0–3), medium-risk (4–5), and high-risk (6–10) groups were identified with significantly different 5-year survival rates ranging 56.9% (95% CI 52.8–60.7%), 46.3% (95% CI 41.1–51.4%), and 32.1% (95% CI 23.5–41.0%), respectively (P < 0.001). External validation showed that the expected survival rates were closely aligned with the observed mortality probabilities. The Retransplantation Risk Score identifies high-risk combinations of recipient- and graft-related factors prognostic for long-term graft survival after reLT. This tool may serve as a guidance for clinical decision-making on liver acceptance for reLT.