肝移植后慢性移植肝失功的病因诊断和治疗18例

目的:探讨肝移植后慢性移植肝失功的病因诊断和治疗.方法:回顾性分析我院1996-01/2006-12完成的291例原位肝移植中18例肝移植后慢性移植肝失功患者的临床资料,总结肝移植后慢性移植肝失功的病因及诊断和治疗.结果:18例肝移植后慢性移植肝失功患者发生反复胆道感染2例、胆管广泛胆泥2例、胆管吻合口狭窄1例、胆管非吻合口狭窄4例、乙型肝炎复发3例、丙型肝炎复发1例、胆汁性肝硬化1例、肝动脉狭窄1例、巨细胞病毒(CMV)感染1例和慢性排斥反应2例.通过各种内科支持治疗、介入治疗或再次肝移植.11例好转,4例病情反复,3例死亡.结论:根据肝移植后慢性移植肝失功的不同病因,可采取不同的治疗手段;对于不可逆转的移植肝功能衰竭,应进行再次肝移植.     

乙型肝炎表面抗原阳性供肝在肝移植中的应用

目的 探讨HBsAg阳性供肝在成人肝移植中应用的安全性及其对患者预后的影响.方法 回顾性分析本中心2007年1月至2010年2月23例接受HBsAg阳性供肝的成人肝移植患者临床资料,患者全部为男性,中位年龄42.5岁(29 ～ 61岁),原发病均为乙型肝炎相关终末期肝病,其中13例术前HBsAg、HBeAg和抗-HBc为阳性,10例术前HBsAg、抗-HBe和抗-HBc为阳性.供体HBsAg均为阳性,术后口服恩替卡韦0.5mg,1次/d,静脉滴注乙型肝炎免疫球蛋白(HBIG),术后1周每天滴注2000 IU.术中及术后采用无激素的免疫抑制方案,术后第1、7、14、21、30天检测患者血清HBsAg、抗-HBs、HBeAg、抗-HBe、抗-HBc、HBV DNA水平,并行肝脏彩色多普勒超声检查.1个月后每月检测及检查1次,并记录患者术后肝功能、肾功能、急性排斥反应、感染、血管并发症、胆道并发症、乙型肝炎复发、肿瘤复发及患者生存等数据.结果 围手术期2例患者死于严重肺部感染,其余21例患者随访至2010年12月(10 ～ 38个月),所有患者术后乙型肝炎未转阴,其中1例患者于术后5个月因胆道缺血再次行肝移植,3例肿瘤患者分别于术后9、14、18个月死于肿瘤复发,18例患者生存,肝功能良好,彩色多普勒超声监测显示肝脏形态、质地良好,HBV DNA监测显示其均为阴性.随访期内,23例患者的生存率为78.3％(18/23),移植肝生存率为73.9％(17/23),未出现乙型肝炎复发所致的肝功能异常、移植肝丢失和病死患者.结论 HBsAg阳性供肝可以安全地应用于乙型肝炎相关终末期肝病的患者.     

活体肝移植治疗重型肝炎的疗效

目的 研究活体肝移植治疗重型肝炎的疗效.方法 选取18例重型肝炎患者为重型肝炎肝移植组,30例失代偿期肝硬化(非肝癌)患者作为肝硬化肝移植组,28例因供肝短缺未行肝移植的重型肝炎患者作为重型肝炎非移植组.术中密切临测患者生命体征,凝血功能,肾功能等.术后患者均行重症监护、免疫抑制治疗、改善肝功能及凝血等,并使用拉米夫定及高价乙型肝炎免疫球蛋白预防乙型肝炎复发.比较3组患者术前情况,手术方式,术后7 d肝、肾功能和并发症,随访1、6、12个月的生存率.实验室检验指标用Wilcoxon秩和检验,率的比较用χ2检验. 结果重型肝炎肝移植组和肝硬化肝移植组患者均采用活体肝移植术,两组患者手术时间,热缺血时间、冷缺血时间和移植物与受体体质量比差异无统计学意义(P值均>0.05),但术中重型肝炎肝移植组患者出血及输血量均多于肝硬化肝移植组(t值分别为0.001和0.004,P值均<0.05).术后7 d,重型肝炎肝移植组总胆红素、ALT和AST分别为(100.5±96.4)μmol/L、(215.3±195.7)U/L和(209.8±188.6)U/L,高于肝硬化肝移植组的(53.3±31.91)μmol/L、(56.3±22.1)U/L和(51.3±13.5)U/L,差异有统计学意义(t值分别为0.017、0.021和0.004,P值均<0.05);白蛋白和肌酐差异无统计学意义(P值均>0.05).术后1、6、12个月生存率,重型肝炎肝移植组分别为88.89%,83.33%、83.33%,肝硬化肝移植组分别为96.67%、93.33%、93.33%.结论 活体肝移植术是治疗重型肝炎的有效方法之一.     

加强肝移植后乙型、丙型肝炎病毒再感染预防和治疗的研究

我国是病毒性肝炎大国，由乙型肝炎或丙型肝炎导致的终末期肝病，包括失代偿性肝硬化、肝癌及肝功能衰竭患者，已越来越多地接受原位肝移植（OLT）治疗。HBV或HCV相关的终末期肝病患者行肝移植后，其预后很大程度上取决于预防和治疗移植肝的再感染。过去的十几年里，尽管在移植后乙型肝炎与丙型肝炎的防治方面取得长足进步，但仍未能完全控制移植后乙型肝炎或丙型肝炎的复发或再感染，当前尚有许多问题急待解决。     

肝移植后远期并发症的病理分析

目的 通过观察肝移植后远期并发症患者的肝组织形态学表现,了解并发症的发生情况.方法 对129例同种异体原位肝移植(OLT)术后远期发生各种并发症的患者行经皮肝穿刺,取肝组织活检标本行HE染色,部分行网状纤维组织染色和免疫组织化学染色,以检测肝组织内乙型肝炎表面抗原、乙型肝炎核心抗原、HCV抗原、巨细胞病毒抗原、EB病毒抗原的表达.对排斥反应病例,依照国际统一的Banff标准进行分级,应用排斥活动指数进行程度评分.结果 129例患者共行肝穿刺168例次,并发症中以急性排斥反应最常见,为61例次(36.31％);其次为药物性肝损伤,共30例次(17.86％),随后依次为丙型肝炎复发21例次(12.5％),乙型肝炎复发15例次(8.93％),胆道并发症14例次(8.33％),慢性排斥反应11例次(6.55％),巨细胞病毒感染6例次(3.57％),血管并发症5例次(2.98％),自身免疫性肝病复发5例次(2.98％).结论 肝移植后经皮肝穿刺活组织检查在多种并发症的诊断及鉴别诊断中具有重要价值.与围手术期不同,轻度急性排斥反应、药物性肝炎和病毒性肝炎复发是肝移植后远期主要的并发症.     

肝移植术后乙型肝炎复发患者的预后分析

目的 分析肝移植术后乙型肝炎复发患者的预后及其相关资料.方法 回顾性分析天津市第一中心医院器官移植中心1998年12月至2009年11月因乙型肝炎相关终末期肝病行肝移植术,且术后接受小剂量乙型肝炎免疫球蛋白联合核苷(酸)类似物预防乙型肝炎复发的1506例患者资料.对其中出现复发病例的资料及其预后进行分析.所有患者术后均行HBV相关血液学检测,检测HBV DNA水平、肝功能,HBV血液学标志物阳性时行肝脏病理学活组织检查,随访至2010年11月.生存分析及复发率采用Kaplan-Meier生存分析,复发率及生存率的比较采用log-rank test检验.结果 共有38例肝移植术后病例确诊为乙型肝炎复发,中位随访时间为45.1个月,非肝癌肝移植患者乙型肝炎中位复发时间为31.8个月(0.3 ～ 72.8个月),肝癌肝移植患者乙型肝炎中位复发时间为13.7个月(0.3 ～ 66.6个月);8例患者检测出HBV耐药基因变异;18例病例接受恩替卡韦或阿德福韦酯挽救治疗,病毒复制转为阴性,肝功能恢复正常;其中22例病例由于肝癌复发、肝功能衰竭及其他原因死亡,16例病例生存.结论 HBV耐药基因变异及肝癌复发是肝移植术后乙型肝炎复发的重要原因,良性肝病肝移植患者乙型肝炎复发后接受阿德福韦酯或恩替卡韦挽救治疗可获得较好预后,而肝癌肝移植术后乙型肝炎复发患者预后较差.     

多次肾移植受者的临床病理特征及预后

目的：探讨多次肾移植受者的临床病理表现及预后。方法：回顾性分析国家肾脏疾病临床医学研究中心2013年1月至2022年10月多次肾移植受者临床病理及预后资料。结果：共纳入38例多次肾移植受者,其中二次肾移植35例、三次肾移植3例。二次肾移植受者首次肾移植肾脏平均存活时间83.2月,29例行二次移植后行移植肾肾活检,肾活检距二次肾移植中位时间31月;病理类型中21例与移植排斥相关,8例为非移植肾排斥反应相关,其中7例复发或新发肾小球疾病。患者二次肾移植中位肾脏存活66(49,108)月,1年、3年和5年肾存活率分别为94.3%、88.6%和60.0%。首次移植肾存活时间≤6月患者和≤1年患者二次移植肾脏存活时间明显低于首次移植肾存活时间>6月患者(P=0.016)和>1年患者(P=0.049)。此外,首次移植肾失功至二次移植间的等待时间≤1年患者二次移植肾脏存活时间明显高于等待时间>1年患者(P=0.022)。3例患者三次移植肾存活时间分别为99月、115月、101月,第1例和第3例移植肾失功。结论：多次移植肾脏预后总体良好,再次移植肾存活时间与首次移植肾脏存活时间及再次...     

肝移植后病毒性肝炎的复发及肝炎病毒再感染

肝移植是目前治疗终末期肝病的有效方法,在我国,病毒性肝炎相关性肝病是接受肝移植患者的主要病因.随着经验的积累,肝移植就手术过程而言已有相当高的成功率,影响术后生存率的主要因素有术后感染、慢性排斥及胆道梗阻、移植后肝炎复发等.众多的研究结果表明,乙型肝炎免疫球蛋白(hepatitis Bimmunoglobulin,HBIG)联合核苷(酸)类似物能显著降低肝移植术后HBV再感染率及肝炎复发率,但该方案仍存在HBIG费用昂贵、使用不便及部分抗HBV药物耐药率高等问题.对于丙型肝炎,目前仍没有特效的预防方案可以很好地预防术后再感染及复发,在移植前用干扰素联合利巴韦林进行抗病毒治疗降低病毒载量可以减少术后复发的机会和严重程度,但由于药物的不良反应、移植术前患者的肝功能状态以及移植时间的不确定性,很难在术前常规对丙型肝炎患者进行抗病毒治疗.     

再次肝移植22例临床病理分析

目的总结分析再次肝移植患者的临床病理特征,提高再次肝移植的临床病理诊断水平。方法回顾性分析我院施行再次肝移植患者的临床病理资料,并进行随访。结果523例接受原位肝移植患者中,共有22例患者接受了23次（4．4％）再次肝移植,再次肝移植的原因主要为胆道并发症13例（59．1％）,肝动脉血栓形成3例（13．6％）,肝细胞性肝癌复发5例（22．7％）,移植肝原发无功能1例（4．5％）。结论肝移植术后的胆道并发症是再次肝移植的最主要原因,肝内广泛胆汁淤积、小胆管增生及以中性粒细胞为主的炎细胞浸润是其重要的病理特征;早期开展计划性肝穿刺,对各种并发症进行鉴别诊断并借助于影像学检查有利于指导临床合理治疗,避免对患者施行再次肝移植。     

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随着移植学突飞猛进的发展,肝移植被广泛应用于治疗终末期肝病,并成为目前治疗终末期肝病的最有效方法。我国是肝病大国,肝病患者超过3000万,90%肝移植患者与乙型肝炎(简称“乙肝”)病毒(HBV)感染有关;尚有部分肝移植患者与丙型肝炎(简称“丙肝”)病毒(HCV)感染相关。本文就国内外防治肝移植术后肝炎复发的进展及存在的问题进行探讨。1预防肝移植后肝炎复发的重要性在我国,与肝炎病毒感染相关的急慢性肝病是肝移植的主要适应证,肝移植后肝炎复发是影响肝移植术后长期存活率的主要因素之一,肝移植受体带毒状况严重影响肝脏移植的肝炎复发…     

Control of intraabdominal hemorrhage and shock: a comparison of fluid resuscitation, MAST, and balloon occlusion

Our study examined the efficacy of four treatment modalities in controlling hemorrhage and achieving hemodynamic stabilization in hemorrhagic shock: intravenous fluid replacement (IV); military antishock trousers used concomitantly with fluids (MAST); balloon occlusion at the level of the diaphragm with concomitant fluid replacement (balloon); and a combination of MAST inflation, balloon occlusion, and fluid resuscitation (MAST and balloon). Twenty-eight mongrel dogs were anesthetized, and the spleen was exposed and completely crushed. The abdomen was closed, and treatment was initiated and continued for four hours or until the dog died. For all conditions the hematocrit dropped during the course of the experiment; balloon occlusion was effective at slowing this drop (P less than .0001), but MAST had no statistically significant effect. Animals with balloons bled more slowly into the abdominal cavity than did animals in the other two groups (P less than .0001). MAST also were effective at slowing the bleeding (P less than .05). Of the balloon and the MAST and balloon dogs, all except one survived the entire four hours; this difference between balloon and nonballoon dogs is significant (P = .002). MAST did not have a statistically significant effect on survival. Perfusion pressure (PP) declined during the course of the experiment, and the balloon was effective at slowing this decline (P less than .0001); none of the other comparisons was statistically significant.     

A Call to Action to Enhance Filovirus Disease Outbreak Preparedness and Response

The frequency and magnitude of recognized and declared filovirus-disease outbreaks have increased in recent years, while pathogenic filoviruses are potentially ubiquitous throughout sub-Saharan Africa. Meanwhile, the efficiency and effectiveness of filovirus-disease outbreak preparedness and response efforts are currently limited by inherent challenges and persistent shortcomings. This paper delineates some of these challenges and shortcomings and provides a proposal for enhancing future filovirus-disease outbreak preparedness and response. The proposal serves as a call for prompt action by the organizations that comprise filovirus-disease outbreak response teams, namely, Ministries of Health of outbreak-prone countries, the World Health Organization, Médecins Sans Frontières, the Centers for Disease Control and Prevention—Atlanta, and others.     

Interplay between interferon-mediated innate immunity and porcine reproductive and respiratory syndrome virus

Innate immunity is the first line of defense against viral infection, and in turn, viruses have evolved to evade host immune surveillance. As a result, viruses may persist in host and develop chronic infections. Type I interferons (IFN-α/β) are among the most potent antiviral cytokines triggered by viral infections. Porcine reproductive and respiratory syndrome (PRRS) is a disease of pigs that is characterized by negligible induction of type I IFNs and viral persistence for an extended period. For IFN production, RIG-I/MDA5 and JAK-STAT pathways are two major signaling pathways, and recent studies indicate that PRRS virus is armed to modulate type I IFN responses during infection. This review describes the viral strategies for modulation of type I IFN responses. At least three non-structural proteins (Nsp1, Nsp2, and Nsp11) and a structural protein (N nucleocapsid protein) have been identified and characterized to play roles in the IFN suppression and NF-κB pathways. Nsp's are early proteins while N is a late protein, suggesting that additional signaling pathways may be involved in addition to the IFN pathway. The understanding of molecular bases for virus-mediated modulation of host innate immune signaling will help us design new generation vaccines and control PRRS.     

Disease Pandemics and Major Epidemics Arising From New Encounters between Indigenous Viruses and Introduced Crops

Virus disease pandemics and epidemics that occur in the world’s staple food crops pose a major threat to global food security, especially in developing countries with tropical or subtropical climates. Moreover, this threat is escalating rapidly due to increasing difficulties in controlling virus diseases as climate change accelerates and the need to feed the burgeoning global population escalates. One of the main causes of these pandemics and epidemics is the introduction to a new continent of food crops domesticated elsewhere, and their subsequent invasion by damaging virus diseases they never encountered before. This review focusses on providing historical and up-to-date information about pandemics and major epidemics initiated by spillover of indigenous viruses from infected alternative hosts into introduced crops. This spillover requires new encounters at the managed and natural vegetation interface. The principal virus disease pandemic examples described are two (cassava mosaic, cassava brown streak) that threaten food security in sub-Saharan Africa (SSA), and one (tomato yellow leaf curl) doing so globally. A further example describes a virus disease pandemic threatening a major plantation crop producing a vital food export for West Africa (cacao swollen shoot). Also described are two examples of major virus disease epidemics that threaten SSA’s food security (rice yellow mottle, groundnut rosette). In addition, brief accounts are provided of two major maize virus disease epidemics (maize streak in SSA, maize rough dwarf in Mediterranean and Middle Eastern regions), a major rice disease epidemic (rice hoja blanca in the Americas), and damaging tomato tospovirus and begomovirus disease epidemics of tomato that impair food security in different world regions. For each pandemic or major epidemic, the factors involved in driving its initial emergence, and its subsequent increase in importance and geographical distribution, are explained. Finally, clarification is provided over what needs to be done globally to achieve effective management of severe virus disease pandemics and epidemics initiated by spillover events.     

Barrett's Esophagus: Where Do We Stand?

Barrett''s esophagus (BE) is a precursor for esophageal adenocarcinoma, which has an increased incidence rate over the last few decades. Its importance stems from the poor five-year survival of esophageal adenocarcinoma and current data that suggest a survival benefit when surveillance programs are implemented. In this review, we will cover the pathophysiology and natural history of BE and the different endoscopic findings. The prevalence of BE in different geographic areas and the incidence of high-grade dysplasia and adenocarcinoma in this patient population is reviewed. Recent recommendation for screening and surveillance of BE has been covered in this review as well as the efficacy of nonconventional imaging modalities and endoscopic ablation therapies.     

The Technology Transfer from Europe to China in the 17th–18th Centuries: Non-Invasive On-Site XRF and Raman Analyses of Chinese Qing Dynasty Enameled Masterpieces Made Using European Ingredients/Recipes

Two masterpieces of the Qing Dynasty (1644–1912 CE), one in gilded brass (incense burner) decorated with cloisonné enamels stylistically attributed to the end of the Kangxi Emperor’s reign, the other in gold (ewer offered by Napoleon III to the Empress as a birthday present), decorated with both cloisonné and painted enamels bearing the mark of the Qianlong Emperor, were non-invasively studied by optical microscopy, Raman microspectroscopy and X-ray microfluorescence spectroscopy (point measurements and mapping) implemented on-site with mobile instruments. The elemental compositions of the metal substrates and enamels are compared. XRF point measurements and mappings support the identification of the coloring phases and elements obtained by Raman microspectroscopy. Attention was paid to the white (opacifier), blue, yellow, green, and red areas. The demonstration of arsenic-based phases (e.g., lead arsenate apatite) in the blue areas of the ewer, free of manganese, proves the use of cobalt imported from Europe. The high level of potassium confirms the use of smalt as the cobalt source. On the other hand, the significant manganese level indicates the use of Asian cobalt ores for the enamels of the incense burner. The very limited use of the lead pyrochlore pigment (European Naples yellow recipes) in the yellow and soft green cloisonné enamels of the Kangxi incense burner, as well as the use of traditional Chinese recipes for other colors (white, turquoise, dark green, red), reinforces the pioneering character of this object in technical terms at the 17th–18th century turn. The low level of lead in the cloisonné enamels of the incense burner may also be related to the use of European recipes. On the contrary, the Qianlong ewer displays all the enameling techniques imported from Europe to obtain a painted decoration of exceptional quality with the use of complex lead pyrochlore pigments, with or without addition of zinc, as well as cassiterite opacifier.