Solid Organ Transplantation After Allogeneic Hematopoietic Stem Cell Transplantation: A Retrospective,Multicenter Study of the EBMT

To analyze the outcome of solid organ transplantation (SOT) in patients who had undergone allogeneic hematopoietic stem cell transplantation (HSCT), a questionnaire survey was carried out within 107 European Group of Blood and Marrow Transplantation centers. This study covered HSCT between 1984 and 2007 in Europe. Forty‐five SOT in 40 patients were reported. Fifteen liver, 15 renal, 13 lung, 1 heart and 1 skin transplantations were performed in 28 centers. Overall survival (OS) of patients after SOT was 78% at 5 years (95% confidence interval [CI], 64% to 92%). OS at 5 years was 100% for renal, 71% (95% CI, 46% to 96%) for liver and 63% (95% CI, 23% to 100%) for lung transplant recipients. The 2‐year‐incidence of SOT failure was 20% (95% CI, 4% to 36%) in patients with graft‐versus‐host disease (GvHD) and 7% (95% CI, 0% to 21%) in patients without GvHD before SOT. The relapse incidence for underlying malignant diseases was 4% at 5 years (95% CI, 0% to 12%). In summary, this study shows that selected patients receiving SOT after HSCT have a remarkably good overall and organ survival. These data indicate that SOT should be considered in selected patients with single organ failure after HSCT.     

Pediatric Transplantation in the United States, 1997–2006

This article represents the sixth annual review of the current state of pediatric transplantation in the United States from the Scientific Registry of Transplant Recipients (SRTR). It presents updated trends, discussion of analyses presented during the year by the SRTR to the committees of the Organ Procurement and Transplantation Network (OPTN) and discussion of important issues currently facing pediatric organ transplantation. Unless otherwise stated, the statistics in this article are drawn from the reference tables of the 2007 OPTN/SRTR Annual Report. In this article, pediatric patients are defined as candidates, recipients or donors aged 17 years or less. Data for both graft and patient survival are reported as unadjusted survival, unless otherwise stated (adjusted patient and graft survival are available in the reference tables). Short-term survival (3 month and 1 year) reflects outcomes for transplants performed in 2004 and 2005; 3-year survival reflects transplants from 2002 to 2005; and 5-year survival reports on transplants performed from 2000 to 2005. Details on the methods of analysis employed may be found in the reference tables themselves or in the technical notes of the 2007 OTPN/SRTR Annual Report, both available online at http://www.ustransplant.org .     

Kidney Transplantation in Previous Heart or Lung Recipients

Outcomes after heart and lung transplants have improved, and many recipients survive long enough to develop secondary renal failure, yet remain healthy enough to undergo kidney transplantation. We used national data reported to United Network for Organ Sharing (UNOS) to evaluate outcomes of 568 kidney after heart (KAH) and 210 kidney after lung (KAL) transplants performed between 1995 and 2008. Median time to kidney transplant was 100.3 months after heart, and 90.2 months after lung transplant. Renal failure was attributed to calcineurin inhibitor toxicity in most patients. Outcomes were compared with primary kidney recipients using matched controls (MC) to account for donor, recipient and graft characteristics. Although 5-year renal graft survival was lower than primary kidney recipients (61% KAH vs. 73.8% MC, p < 0.001; 62.6% KAL vs. 82.9% MC, p < 0.001), death-censored graft survival was comparable (84.9% KAH vs. 88.2% MC, p = 0.1; 87.6% KAL vs. 91.8% MC, p = 0.6). Furthermore, renal transplantation reduced the risk of death compared with dialysis by 43% for KAH and 54% for KAL recipients. Our findings that renal grafts function well and provide survival benefit in KAH and KAL recipients, but are limited in longevity by the general life expectancy of these recipients, might help inform clinical decision-making and allocation in this population.     

肝小肠联合移植的术式探讨及术后处理一例

目的 总结1例保持门静脉连续性的小肠双造口方式肝小肠联合移植病例的手术操作和术后处理的经验.方法 受者为短肠综合征合并肝功能不良的男性患者,供者为尸体供者.联合切取器官,确保供者肠系膜上静脉和门静脉的连续性.移植肝静脉采用背驼式吻合,受者自体门静脉和供肝门静脉端侧吻合,胆道端端吻合,供者肝动脉和肠系膜上动脉吻合于受者腹主动脉;移植小肠约2 m,两端双造口于腹壁,未作肠道吻合.采用人源化抗CD52单克隆抗体诱导治疗,维持期单用他克莫司.行内镜下黏膜活检监测排斥反应.结果 术后1个月内,患者发生腹腔感染和疑似排斥反应各1次,分别经过手术和甲泼尼龙冲击治疗后痊愈.随访6个月,受者移植肝和小肠功能恢复良好,但仍有腹泻,需补充静脉营养,体重尚未完全恢复.结论 保持门静脉连续性的小肠双造口方式肝小肠联合移植可以简化手术操作,发生外科并发症的风险小,有利于肝脏和小肠功能恢复及术后排斥反应的监测,但是消化液未能进入移植小肠,也影响了受者的恢复.     

接受同一供体肝肾联合移植与肾移植的临床研究

目的探讨肝肾联合移植肝脏对肾脏的保护作用。方法我院移植中心2002年5月至2006年9月间共进行8例肝肾联合移植手术，对此8例患者及接受同一供体对侧供肾8例肾移植患者及移植物存活率、排斥反应发生率进行分析。结果肝肾联合移植患者及移植物存活率为100％，无可证实排斥反应发生。术后8例患者移植肝功能迅速恢复正常，7例移植肾功能迅速恢复正常，1例移植肾发生急性肾小管坏死，于术后第52天肾功能恢复正常。对应8例单纯肾移植患者，发生急性排斥反应1例，予甲基强的松龙冲击治疗及应用抗人T淋巴细胞免疫球蛋白（anti-thymocyte globulin，ATG）后，于术后50d移植肾功能恢复正常，余7例患者恢复良好，至末次随访肾功能均正常。结论肝肾联合移植肝脏对肾脏有一定的保护作用。     

自体毛发移植的临床应用

目的：探索应用自体毛发移植术治疗各种原因引起的秃发及眉毛、睫毛和阴毛缺损。方法：切取后枕部适量条形头皮组织，根据需要将其制备成单株及多株(4-10株)移植物。然后，将这些移植物以缝隙切开多株植入加单株法植入脱发区，以单株法植入眉、睫毛缺损区及阴阜部。结果：自1997年6月至2001年10月，完成修复秃发31例，眉缺损192例(384侧)，睫毛缺损67例(134侧)，阴毛缺失12例，共302例，均取得满意的美容效果。毛发成活率可达70％-90％。一年后，随访观察毛发生长自然。结论：自体毛发移植根据缺损部位采用不同方法可取得较为满意的临床疗效，并且操作简便、安全，恢复快。     

Present status and future perspectives of intestinal transplantation.

Intestinal transplantation (ITx) is the only definitive therapy for irreversible intestinal failure. Owing to the limited short- and long-term graft survival over the years, ITx has been a complementary treatment to home parenteral nutrition. However, the development of intestinal and multivisceral transplantation has been significant over the past 15-20 years owing to the progress in immunosuppressive therapy, refinement of surgical techniques, post-transplant care, intestinal immunology, and immunological as well as anti-infectious monitoring. The improvement of patient- and graft survival over the last few years together with data on the cost effectiveness of ITx, following 2 years after transplantation, may require a redefinition of the indication for ITx.     

The First Report of Orthotopic Liver Transplantation in the Western World

Until the present time, the first experimental liver transplant which led to the development of human liver transplantation is attributed to C. Stuart Welch who performed a heterotopic transplant in the canine species in 1955. In 1956, Jack Cannon is credited with the first animal orthotopic liver transplant although the species was not disclosed. This report is intended to set the historical record straight by acknowledging that Vittorio Staudacher in 1952 was the first to perform a liver transplant in a large animal model.     

Simultaneous Thoracic and Abdominal Transplantation: Can We Justify Two Organs for One Recipient?

Simultaneous thoracic and abdominal (STA) transplantation is controversial because two organs are allocated to a single individual. We studied wait‐list urgency, and whether transplantation led to successful outcomes. Candidates and recipients for heart–kidney (SHK), heart–liver (SHLi), lung–liver (SLuLi) and lung–kidney (SLuK) were identified through the United Network for Organ Sharing (UNOS) and outcomes were compared to single‐organ transplantation. Since 1987, there were 1801 STA candidates and 836 recipients. Wait‐list survival at 1‐ and 3 years for SHK (67.4%, 40.8%; N = 1420), SHLi (65.7%, 43.6%; N = 218) and SLuLi (65.7%, 41.0%; N = 122), was lower than controls (p < 0.001), whereas for SLuK (65.0%, 51.6%; N = 41) it was comparable (p = 0.34). All STA groups demonstrated similar 1‐ and 5 years posttransplant survival to thoracic controls. Compared to abdominal controls, 1‐ and 5 years posttransplant survival in SHK (85.3%, 74.0%; N = 684), SLuLi (75.5%, 59.0%; N = 42) and SLuK (66.7%, 55.6%; N = 18) was decreased (p < 0.01), but SHLi (85.9%, 74.3%; N = 92) was comparable (p = 0.81). In summary, STA candidates had greater risk of wait‐list mortality compared to single‐organ candidates. STA outcomes were similar to thoracic transplantation; however, outcomes were similar to abdominal transplantation for SHLi only. Although select patients benefit from STA, risk‐exposure variables for decreased survival should be identified, aiming to eliminate futile transplantation.     

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目的 报告国内首例同种异体肝小肠联合移植，并就肝肠联合移植适应证、排斥诊断与治疗、感染防治、肠功能恢复与营养支持进行讨论。方法 供肠长380cm，供肠肠系膜上动脉、门静脉分别与受体腹主动脉、下腔静脉端侧吻合；供肝行改良背驮式肝移植。术后免疫抑制剂采用FK506 激素 骁悉 赛尼哌方案。排斥监测采用内镜指导下肠粘膜活检病理学检查及临床观察。并采取措施防治感染和促进移植肠功能的恢复。结果病人恢复顺利，移植肠和移植肝功能良好，未发生排斥反应，术后3个月时已摆脱全肠外营养，依靠肠内营养维持营养状态。结论 肝小肠联合移植对肠衰竭合并全肠外营养所致肝功能损害病人，是可行、有效的治疗方法。     

临床肝肾移植三例体会

目的　探讨肝肾序贯移植和同期联合移植的手术难点及围手术期处理要点。方法　对2例肾移植术后发生药物性肝损害的病例实施肝移植 ,并对 1例巨大多囊肝、多囊肾的病例实施肝肾联合移植。结果　 2例肾移植术后实施肝移植的病例 ,其中 1例因术后肾功能衰竭导致多器官功能衰竭死亡 ;另 1例术后肝、肾功能良好 ,现已存活 1年。肝肾联合移植病例术中采用肝后腔静脉直接阻断法 ,使重达 10kg的巨大病肝得以顺利切除 ,并采用腔静脉成型术完成改良背驮式肝移植。术后免疫方案采用人源化单克隆抗体达利珠单抗免疫诱导下的以FK5 0 6、霉酚酸酯 (MMF)和激素的三联用药 ,肝、肾功能恢复良好 ,现为术后 6个月。结论　序贯性肝肾移植在术前应该准确评估移植肾功能 ,如果移植肾功能不良 ,应果断选择实施肝肾联合移植。肝后下腔静脉直接阻断法在实施巨大病肝切除时具有较大优势。肝肾联合移植术中及术后建议采用达利珠单抗免疫诱导下的免疫三联用药。     

肝、肾联合移植12例报告

目的 对肝、肾联合移植的临床情况进行总结。方法 为12例肝、肾功能异常患者施行肝、肾联合移植，采用多器官联合切取术整块切取供者器官。8例行经典式肝移植，4例行背驮式肝移植，均未行体外静脉转流；肾移植为常规术式。术前进行抗CD25单克隆抗体和抗胸腺细胞球蛋白诱导治疗，术后应用他克莫司（FK506）、霉酚酸酯及泼尼松预防排斥反应。结果 12例手术均获成功，移植肝及肾功能恢复良好。术后的并发症有移植肝急性排斥反应、FK506中毒、消化道出血、腹腔出血、肺部感染、腹腔感染（各1例次），所有患者均未发生移植肾急性排斥反应。结论 肝、肾联合移植是治疗终末期肝病合并肾功能衰竭的理想选择。     

Lung and heart-lung transplantation

This report is a brief summary on current events related to lung and heart-lung transplantation. Eleven patients have undergone transplantation of the heart and both lungs at Stanford University. The ages ranged from 22–45, the average age being about 36 years, and included were four females and seven males. The diagnosis was primary pulmonary hypertension in three and Eisenmenger syndrome-congenital heart disease with pulmonary hypertension-in eight. Eight patients are living and well, two to more than 24 months after transplantation of the heart and both lungs. All these patients were discharged and are fully rehabilitated, which is an important consideration. There have been three operative deaths, one was secondary to two previous operations that made our operation much too long, another was secondary to the use of intravenous cyclosporine, and the third was related to the poor maintenance of the donor lung. Three of the eleven patients were catheterized following the transplant from six months to a year after transplantation, and the pulmonary artery pressure and pulmonary vascular resistance were absolutely normal in all three of these individuals. Of course the plan is to go ahead with further catheter studies at yearly intervals in all of the patients. The last patient underwent transplantation in January, 1983. I think no matter how effective or how ingenious the medical staff is with artificial organs, it will be a long time before these early results of transplantation of the heart and both lungs can be matched by any types of artificial organ implants. Supported in part by a grant (HL 13108) from the National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland, and from the Dr. Ralph and Marian Falk Foundation for Medical Research Gist of a Lecture given at the Japan Surgical Society, April 7, 1983.     

Intestinal and multivisceral transplantation

Intestinal and multivisceral transplantation represents an important treatment option for patients with intestinal failure. Early attempts were hindered by technical and immunological complications. However, significant developments in immunosuppressive therapy have led to marked improvements in outcomes in recent years. The main indications for intestinal transplantation are life-threatening complications or unacceptable quality of life on total parenteral nutrition (TPN), or following evisceration for extensive intra-abdominal tumours. In suitable patients, in the absence of significant liver disease, an isolated intestinal graft is appropriate. A combined liver and intestinal transplant is indicated in patients with significant liver disease, almost always as a result of long-term TPN. Pathology affecting the foregut may require more extensive grafts including the stomach, duodenum and pancreas. Multivisceral transplantation is technically demanding. The transplant recipient has frequently undergone multiple previous laparotomies and may present with multiple stomata, fistulae, collections, distortion of intra-abdominal anatomy and significant contraction of the abdominal cavity. The most important early complications are acute rejection and sepsis, which frequently occur together. In the long-term, chronic rejection and malignancy are the leading causes of graft loss and mortality and immunosuppression related renal impairment a major source of morbidity. It is hoped that ongoing improvements in intestinal and multivisceral transplantation may eventually justify its use as a primary alternative to long-term TPN.     

肝肾联合移植的临床经验

目的 探讨肝肾联合移植的适应证、手术技术、治疗经验及并发症防治。方法2001年10月至2005年3月进行肝肾联合移植13例。男12例，女1例。年龄41—66岁，平均54岁。原发病：多囊肝、多囊肾并尿毒症3例，酒精性肝硬化合并尿毒症2例，乙型肝炎肝硬化合并尿毒症7例，肾移植术后14年丙型肝炎肝硬化导致肝衰竭伴移植肾功能不全尿毒症1例。肝移植采用经典非转流原位肝移植术式和背驮式肝移植术式，肾移植为常规术式。病肝切除时注意细致分离第三肝门、创面及时止血。以抗胸腺细胞球蛋白或白细胞介素-2受体单克隆抗体作为免疫诱导，术后服用他克莫司、吗替麦考酚酯及激素维持免疫抑制治疗。患者门诊随访，复查血、尿常规．肝肾功能，他克莫司血药浓度以及移植物B超等。随访时间12—53个月。结果13例手术均成功。术后发生急性排斥反应1例，继发性出血1例，心肌梗死1例（死亡），胸腔积液4例，肺部感染3例（1例死亡）。除死亡病例外，所有并发症经相应治疗后逆转治愈。11例存活者肝肾功能正常，其中存活4年5个月者1例，存活3年以上者2例，2年以上者6例，1年以上者2例。1例49岁患者术后18个月死于心肌梗死，1例52岁患者术后13个月死于肺部巨细胞病毒感染。结论 肝肾联合移植是肝肾功能衰竭的有效治疗手段。娴熟的手术技巧和并发症的及时诊治是肝肾联合移植成功的关键。     

Intestinal and multivisceral transplantation

Intestinal and multivisceral transplantation represents an important treatment option for patients with intestinal failure. Early attempts were hindered by technical and immunological complications. However, significant developments in immunosuppressive therapy have led to marked improvements in outcomes in recent years. The main indications for intestinal transplantation are life-threatening complications or unacceptable quality of life on total parenteral nutrition (TPN), or following evisceration for extensive intra-abdominal tumours. In suitable patients, in the absence of significant liver disease, an isolated intestinal graft is appropriate. A combined liver and intestinal transplant is indicated in patients with significant liver disease, almost always as a result of long-term TPN. Pathology affecting the foregut may require more extensive grafts, including the stomach, duodenum and pancreas. Multivisceral transplantation is technically demanding. The transplant recipient has frequently undergone multiple previous laparotomies and may present with multiple stomata, fistulae, collections, distortion of intra-abdominal anatomy and significant contraction of the abdominal cavity. The most important early complications are acute rejection and sepsis, which frequently occur together. In the long term, chronic rejection and malignancy are the leading causes of graft loss and mortality and immunosuppression related renal impairment a major source of morbidity. It is hoped that ongoing improvements in intestinal and multivisceral transplantation may eventually justify its use as a primary alternative to long-term TPN.     

Intestinal and multivisceral transplantation

Intestinal and multivisceral transplantation represents an important treatment option for patients with intestinal failure. Early attempts were hindered by technical and immunological complications. However, significant developments in immunosuppressive therapy have led to marked improvements in outcomes in recent years. The main indications for intestinal transplantation are life-threatening complications or unacceptable quality of life on total parenteral nutrition (TPN), or following evisceration for extensive intra-abdominal tumours. In suitable patients, in the absence of significant liver disease, an isolated intestinal graft is appropriate. A combined liver and intestinal transplant is indicated in patients with significant liver disease, almost always as a result of long-term TPN. Pathology affecting the foregut may require more extensive grafts including the stomach, duodenum and pancreas. Multivisceral transplantation is technically demanding. The transplant recipient has frequently undergone multiple previous laparotomies and may present with multiple stomata, fistulae, collections, distortion of intra-abdominal anatomy and significant contraction of the abdominal cavity. The most important early complications are acute rejection and sepsis, which frequently occur together. In the long-term, chronic rejection and malignancy are the leading causes of graft loss and mortality. It is hoped that ongoing improvements in intestinal and multivisceral transplantation may eventually justify its use as a primary alternative to long-term TPN.