肝硬化患者原位肝移植术后的内脏循环血流动力学变化

目的　探讨肝硬化患者背驮式原位肝移植 (PBOLT)术后 1年内内脏循环血流动力学变化。方法　 15例因肝硬化行PBOLT患者 ,分别于术前和术后 1～ 3d ,7～ 15d ,3～ 6个月 ,1年应用彩色多普勒血流显像仪 (CDFI)测定门静脉血流平均流速 (PBV)、门静脉血流量 (PBF)、肝动脉搏动指数 (HA PI)、脾动脉阻力指数 (SA RI)、脾脏纵向直径 (LDS)、肠系膜上动脉搏动指数 (SMA PI)等血流动力学指标 ,并与 10例正常人进行对照。结果　PBV ,HA PI ,SA RI等血流动力学指标在肝移植术后 1年内基本恢复正常 ( P >0 .0 5 ) ;LDS明显缩小 ,但仍高于正常值 ;PBF于术后 1年仍较正常对照值高 ( P<0 .0 5 ) ;SMA PI于术后 1年较术前有所恢复 ,但仍低于正常对照值 (P <0 .0 5 )。结论　肝硬化患者的内脏循环血流动力学紊乱在原位肝移植 1年内绝大部分得到恢复。说明肝移植术本身并不导致术后高血流动力学的发生 ,肝硬化患者肝移植后的早期内脏血流动力学紊乱可能与移植前已存在的病理生理因素有关     

经典非转流原位肝移植术后早期肾功能障碍的原因分析

目的观察经典非转流原位肝移植（orthotopic liver transplantation,OLT）术后早期肾功能障碍（renal dysfunction,RD）发生的原因并提供临床参考.方法前瞻性研究了连续48例经典非转流OLT病例,根据术后早期（术后第1周）血清肌酐水平进行分组.对单因素分析后有显著性差异的资料进行多因素回归分析.结果经典非转流OLT术后早期RD的发生率为35.4%.Binary Logistic多元回归分析显示：术前RD、Child-Pugh评分、无肝期门静脉开放后1 h尿量是该术后早期RD的危险因素.结论对于术前明显肾功能障碍或Child-Pugh评分较高的病人,应避免使用经典非转流术式.对于接受经典非转流手术的病人,术前应纠正肾功能异常;术中应避免血流动力学的剧烈波动,保持稳定有效的肾血流灌注,以减少术后早期RD的发生.     

肝移植术中脾肾分流的个体化处理

目的评估肝移植术中个体化处理脾肾分流的安全性和有效性。方法回顾性分析2例行原位肝移植并术中处理脾肾分离的受者临床资料,根据脾肾分流和供肝复流后灌注情况,2例受者术中分别行左肾静脉结扎术和脾肾分流血管结扎术。观察受者的术后一般情况,包括手术相关并发症、门静脉血流峰值速度、肝功能和肾功能指标。通过腹部超声监测受者术后情况。结果 2例受者术中及术后均未出现手术相关并发症。病例1和病例2脾肾分流前后门静脉血流峰值速度的变化分别为22.9～35.1 cm/s、24.3～58.8 cm/s。2例受者术后丙氨酸转氨酶(ALT)未出现延迟恢复。病例1受者术后出现一过性血清肌酐(Scr)升高,于术后13 d恢复正常。术后随访过程中,超声检查显示门静脉血流方向和速度正常,肝脏灌注良好。结论肝移植术中对合并严重脾肾分流的受者选择性结扎其左肾静脉或脾肾分流血管是安全和有效的。     

肝硬化鼠肝移植后早期全身和内脏血流动力学的变化

目的 观察正常鼠肝移植及及肝硬化鼠肝移植术早期全身和内脏血流动力学的变化。方法 实验动物随机分为正常鼠（NL,10只）、肝硬化鼠（IHPH,10只）、正常鼠肝移植（NL－OLT,9只）、肝硬化鼠肝移植（IHPH－OLT,16只）组。分别采用放射性微球法行血流动力学研究。结果 NLOLT鼠绝大多数血流动力学参数与NL鼠比较差异无显著意义。IHPH及IHPH－OLT 3d,7d组心输量和内脏血流量和内脏血流量增加,平均动脉压、周围血管总阻力和内脏血管阻力降低。内脏血流动力学紊乱较全身明显。结论 肝硬化鼠肝移植后的血流动力学紊乱可能与移植前已存在的病理生理因素有关。     

血管活性物质在肝硬化肝移植后高血流动力学中的作用

目的：探讨内源性血管活性物质在肝硬化鼠肝移植后设备在流动力学中的作用,方法：雄性SD大鼠随机分为四组,正常对照组（NL）,肝硬化组（IHPH）,正常鼠肝移植组（NL－OLT）和肝硬化地移植组（IHPH－OLT）,IHPH－OLT鼠又分为术后3天（A组）和7天（B组）两个亚组,IHPH模型肌注CCI4制备,大鼠OLT模型采用三袖套法,血流动力学研究采用放射性微球注射技术,血浆胰高糖素（Glu),一氧化氮（NO）,前列环环素（PGI2）,血栓素（TXA2）以及内皮素（ET）浓度用放射免疫法测定,结果：NL－OLT鼠绝大多数血流动力学参数与NL鼠比较差异无显著意义（P＞0．05）,与NL鼠比较,NL－OLT鼠的NO和PGI2均无明显变化,而Glu,ET 和TXA2水平显著地升高（P＜0．05）,IHPH,IHPH－OLT A,B鼠均具有全身和内脏高血流动力学特征,其高动力循环的程度和血管扩张物质NO和Glu增加的程度均是IHPH＞IHPH－OLTA＞IHPH－OLTB鼠的PGI2显著地高于NL鼠,IHPH－OLTA、B鼠的PGI2显著地低于IHPH鼠（P＜0．05）,而HPH－OLTB鼠与NL鼠比较已无显著差异,血管收缩物质ET和TXA2在肝硬化肝移植术后均有不同程度升高,结论：肝移植术本身并不导致术后高血流动力学的发生,血管扩张物质NO和Glu,尤其是NO在IHPH以及IHPH－OLT鼠的高动力循环中起重要作用,肝硬化肝移植后早期依然存在的高动力循环是术前引起高血流动力学发病因子升高的原因未消除的结果。     

背驮式肝移植的技术改进(附一例报告)

目的 探讨更完善的背驮式肝移植术式。方法 保留受者的腔静脉、肝静脉全部结扎,在受者的下腔静脉上开一侧孔,将供肝腔静脉近端与受者的下腔静脉侧孔行端侧吻合,远端缝扎。术中测定受者各时相的血流动力学参数。结果 无肝期为５０例,整个手术历时８小时,术中失血２５００ｍｌ。术中血流动力学平稳。术后肝功能指标大部分恢复正常,胆汁引流量约２００ｍｌ／ｄ。术后第５８天因肾功能衰竭死亡。结论 本术式适合于良性终末期肝     

亲体原位部分肝移植术后血流动力学的变化

目的 探讨亲体原位部分肝移植术后血流动力学的变化。方法 应用彩色多普勒血流显像仪检查10例正常人和7例亲体原位部分肝移植术前、后的肝血流动力学改变。结果 6例肝移植术后经过正常，门静脉、肝动脉、肝静脉的血流于术后1－5个月逐渐恢复正常。1例肝移植术后出现并发症。肝动脉血流速度低于28cm/s，血流呈扑动状，同时阻力指数增至0.78，提示肝动脉血栓形成。结论 彩色多普勒血流影像在肝移植术前、后可有效监测肝血流动力学变化，可早期发现一些致命的并发症，为临床早期处理提供准确依据，对保证肝移植成功有着重要的临床意义。     

胰肾联合移植治疗肝移植后糖尿病合并肾功能衰竭二例

目的 总结肝移植后再行胰肾联合移植治疗糖尿病合并肾功能衰竭的临床处理经验.方法 2例肝移植受者术前合并有2型糖尿病,分别于肝移植后7年余和4年余发生肾功能衰竭,遂行胰肾联合移植,2例的移植肝功能均正常.采取腹部器官联合快速切取技术整块切取双肾、全胰及十二指肠节段,先行肾移植,再行胰腺移植,供肾移植于左侧髂窝,供胰移植于右侧髂窝,供者的十二指肠与受者的空肠侧侧吻合,供者的十二指肠内置管,通过受者的空肠引流出体外.例1采用抗白细胞介素受体单克隆抗体诱导的四联免疫抑制方案预防排斥反应;例2术中给予抗胸腺细胞球蛋白和甲泼尼龙,术后继续使用2d,采用他克莫司+吗替麦考酚酯+皮质激素预防排斥反应.结果 2例手术过程顺利,术后移植胰腺功能正常,血糖均于术后10d左右恢复正常,无需胰岛素治疗,移植肾功能1周时恢复正常,第2例1周后血清肌酐渐进性升高,经验性抗排斥反应治疗效果不明显,移植肾活组织检查未见明显排斥反应征象,遂将他克莫司替换为西罗莫司,之后受者的肾功能逐渐恢复正常.目前2例受者已分别随访36个月及9个月,移植肝、肾及胰腺功能均正常.结论 肝移植后合并糖尿病、肾功能衰竭时可考虑行胰肾联合移植,但术后免疫反应复杂,需严密监测移植物功能.     

猪解剖生理学特点对猪原位肝移植的影响

目的 探讨猪原位肝移植模型的建立。方法 根据猪的解剖生理学特点，采用体外静脉转流技术进行猪原位肝移植（OLT）。结果 16只OLT术后存活14只，手术成功率87.5%，术中血流动力学、血气电解质及体温均能维持在正常范围。结论 猪原位肝移植过程中，采用体外静脉转流技术，以及根据猪的解剖生理学特点，改进和完善手术技巧是手术成功的关键。     

原位肝移植术后肺部感染与易感因素分析

目的 探讨原位肝移植（OLT）术后肺部感染的特点和易感因素。方法 回顾性总结128例原位肝移植的临床资料，分析肺部感染的主要致病菌、感染发生的时间及易感因素。结果 128例患者OLT术后共发生肺部感染48例（37．5％），其中27例（56．3％）发生在术后7d内，34例（70．8％）为混合感染；死亡6例（12．5％），其余治愈。致病菌前几位依次为铜绿假单胞菌，鲍曼／溶血不动杆菌、金黄色葡萄球菌和曲霉菌。结论 多种病菌可致肝移植术后肺部感染，并与受者的体质、机械通气及免疫抑制剂应用等诸多因素有关。     

Endothelin activation and postoperative renal failure after human liver transplantation.

Renal failure is an established risk factor for impaired patient outcome after orthotopic liver transplantation (OLT). As the endothelin pathway is known to be involved in the development of acute renal failure (ARF), we designed a study to clarify its role in ARF following OLT. Twenty consecutive patients with intact kidney function scheduled for their first OLT were prospectively studied. Plasma big endothelin-1 (ET-1) levels were measured before surgery, after graft reperfusion, and on the first and second postoperative day. According to postoperative glomerular filtration rate (GFR), patients were assigned to the acute renal dysfunction group (ARDF) and the non-ARDF group. Each patient's GFR was estimated according to the 4-variable formula used in the modification of diet in renal disease before surgery, daily within the first postoperative week, and at 1, 3, 12, and 24 months after surgery. Postoperative mean big ET-1 levels correlated significantly with the maximum percent decrease of GFR within 3 days after OLT (P < 0.01). The proportion of patients who developed ARDF was significantly correlated to mean postoperative big ET-1 quartiles (P < 0.01). In the ARDF group, the percent decrease of GFR within 24 months was significantly higher (P < 0.05) as compared to the non-ARDF group. In conclusion, patients who develop ARDF immediately after OLT do not fully recover to baseline regarding long-term kidney function. Short-term GFR was significantly correlated with postoperative big ET-1 plasma levels, suggesting renal dysfunction is mediated by the activated endothelin system.     

The Impact of Aprotinin on Renal Function After Liver Transplantation: An Analysis of 1043 Patients

Renal dysfunction is frequently seen after orthotopic liver transplantation (OLT). Aprotinin is an antifibrinolytic drug which reduces blood loss during OLT. Recent studies in cardiac surgery suggested a higher risk of postoperative renal complications when aprotinin is used. The impact of aprotinin on renal function after OLT, however, is unknown. In 1,043 adults undergoing OLT, we compared postoperative renal function in patients who received aprotinin (n = 653) or not (n = 390). Using propensity score stratification (C-index 0.82) and multivariate regression analysis, aprotinin was identified as a risk factor for severe renal dysfunction within the first week, defined as increase in serum creatinine by >or= 100% (OR = 1.97, 95% CI = 1.14-3.39; p = 0.02). No differences in renal function were noted at 30 and 365 days postoperatively. Moreover, no significant differences were found in the need for renal replacement therapy (OR = 1.52, 95% CI = 0.94-2.46; p = 0.11) or in 1-year patient survival rate (OR = 1.14, 95% CI = 0.73-1.77; p = 0.64) in patients who received aprotinin or not. In conclusion, aprotinin is associated with a higher risk of transient renal dysfunction in the first week after OLT, but not with a higher need for postoperative renal replacement therapy or an increased risk of mortality.     

Orthotopic liver transplantation with vena cava preservation in cirrhotic patients: is systematic temporary portacaval anastomosis a justified procedure?

INTRODUCTION: We evaluated the peri- and postoperative effects of the lack of a temporary portocaval anastomosis (TPCA) during orthotopic liver transplantation (OLT) in 84 patients with cirrhosis. PATIENTS AND METHODS: From December 1996 to December 2002, 156 liver transplant recipients included (54%; 60 men and 24 women) of mean age 52 +/- 9 years with portal hypertension. In whom peri- and postoperative data were analyzed. RESULTS: The median fall in mean arterial pressure upon vascular clamping and unclampings was 20 mm Hg (range 15 to 75), while the median duration of portal vein clamping was 77 minutes. The median amount of blood autotransfusion was 1100 mL (range 0 to 5400). The median number of red blood cell and fresh-frozen plasma units transfused were 5 and 6.5, respectively. The median intraoperative urinary output was 72 mL/h (range 11 to 221). Three patients (3.5%) presented a perioperative complication, but no perioperative death was observed. Six patients experienced an early postoperative complication (<10 days): five hemodynamic complications and one transient renal failure, which did not require hemodialysis. One patient (1%) died at 12 hours after OLT from acute pulmonary edema. CONCLUSION: This study shows that systematic TPCA during OLT with preservation of the native retrohepatic vena cava in cirrhotic patients does not appear to be justified. In contrast, peri- and postoperative hemodynamic parameters as well as blood component requirements were comparable to those of the literature reporting OLT with straightforward TPCA.     

Intraabdominal pressure in liver transplant recipients: incidence and clinical significance

BACKGROUND: The incidence and clinical relevance of increased intraabdominal pressure after orthotopic liver transplantation (OLT) has not yet been evaluated despite the finding that occurrence of this condition in postsurgical critically ill patients may impair various organ functions. The aim of this study was to assess whether the occurrence of abdominal hypertension among a population of OLT recipients was an important cofactor producing early postoperative complications. METHOD: This prospective clinical study measured abdominal pressure every 6 hours during the intensive care unit (ICU) stay using the urinary bladder method. A value of >/=25 mm Hg was considered high. Hemodynamic status was simultaneously evaluated and renal function assessed based on the hourly urinary output, and by calculating serum creatinine on postoperative days 2 and 4. Renal failure was defined as a serum creatinine level of >1.5 mg/dL, or an increase in peak of >1 mg/L within 72 hours of surgery. The filtration gradient and patient outcomes were also considered. RESULTS: Intraabdominal hypertension was observed in 32% of cases. The subjects displaying high IAP showed significantly lower artery pressure values (P <.01), but did not differ in terms of central venous pressure or cardiac output. High intraabdominal pressure was more frequently associated with renal failure (P <.01), a lower filtration gradient (P <.001), delayed postsurgical weaning from the ventilation (P <.001), and increased ICU mortality (P <.05). A receiver operator characteristic curve analysis showed that the critical IAP values, namely those with the best sensitivity/specificity, were 23 mm Hg for postoperative ventilatory delayed weaning (P <.05), 24 mm Hg for renal dysfunction (P <.05), and 25 mm Hg for death (P <.01). CONCLUSIONS: Abdominal hypertension occurs frequently after OLT and may be associated with a complicated postoperative course.     

门静脉高压症原位肝移植前后内脏血流动力学变化的临床研究

目的 研究门静脉高压症原位肝移植前后内脏血流动力学变化及其对脾功能亢进、侧支循环、术后肝功能恢复的影响.方法 2002年6月至2005年10月上海交通大学医学院附属瑞金医院外科共完成173例原位肝移植术.选取其中38例肝硬化门静脉高压症患者,分别于术前、术后1、3、5、7 d、1个月、6个月、1、2、3年行彩色多普勒超声检查,监测患者门静脉血流平均速度、门静脉血流量、肝动脉阻力指数等血流动力学指标和脾脏大小变化,并与8例急性重症肝炎患者及20名健康人进行对照,同时观察其对肝功能和食管胃底曲张静脉的影响.结果 肝硬化门静脉高压症患者术后门静脉血流平均速度从术前(13.7±4.2)cm/s升至(58.4±25.2)cm/s,门静脉血流量从(958±445)ml/min升至(3024±1207)ml/min,肝动脉阻力指数从0.65±0.11升至0.74±0.12,均明显高于急性重症肝炎组和正常对照组(P<0.05),门静脉血流平均速度和门静脉血流量分别于术后6个月、2年降至正常对照组水平.肝硬化门静脉高压症组术后脾功能亢进从术后第2天开始改善,至术后1个月完全恢复,但脾脏肿大在术后3年仍然存在.术后食管胃底曲张静脉亦明显改善.结论 肝硬化门静脉高压症患者原位肝移植术后内脏高血流动力学仍将长期存在,但并不影响脾功能亢进和食管胃底静脉曲张以及肝功能的恢复.     

Evolution of hepatorenal syndrome after orthotopic liver transplantation: comparative analysis with patients who developed acute renal failure in the early postoperative period of liver transplantation

OBJECTIVE: The purpose of this study was to ascertain the prognosis of patients with hepatorenal syndrome (HS) prior to orthotopic liver transplantation (OLT) by comparisons with a group of selected patients with normal renal function (NRF) pretransplantation who developed acute renal failure (ARF) in the early postoperative period. MATERIALS AND METHODS: Fifty-two OLT cases developed ARF in the early postoperative period between March 1999 and October 2004; 17 cases experienced HS prior to OLT. ARF was defined as serum creatinine level (Cr) >1.5 mg/dL or a creatinine clearance (CrCl) <50 mL/min. The immunosuppressive therapy was the same in both groups: low doses of tacrolimus were prescribed to reach trough levels of 5 ng/mL in the first week after OLT, where patients were administered monoclonal antibodies and corticosteroids. RESULTS: No differences were observed between the groups for gender, age or APACHE II Score in the first 24 hours after OLT. Patients with HS pretransplantation showed higher Cr and urea (U) levels than the other group (Cr: 2.1 +/- 0.8 HS vs 0.9 +/- 0.2, P = .000; U: 93.6 +/- 51.9 HS vs 42.1 +/- 19.3, P = .001). The ICU days of stay were similar (12.8 +/- 0.5 HS vs 19.7 +/- 15.2, P = .053). At the end of 1 year follow-up after OLT there were no differences in mortality (35% HS vs 26%), need for renal replacement therapy (23% HS vs 34%), infection (59% HS vs 51%), or rejection (6% HS vs 29%, P = .06). CONCLUSIONS: Patients with HS prior to OLT showed a similar prognosis to a group of selected patients with NRF pretransplantation, but developed ARF in the early postoperative period which was treated with monoclonal antibodies and low doses of tacrolimus.     

肾移植前后妇女的生育力和相关激素研究

本研究应用酶免疫法检测了肾移植前、后共40例女性患者的性激素水平，并以15例近龄健康妇女作对照，结果发现肾移植受者的PRL（泌乳素），FSH（促卵泡素）及LH（促黄体素）较慢性肾功能衰竭（CRF）血液透析组明显降低，而E2（雌二醇）；和P（孕酮）在正常范围。结论：认为成功肾移植后可纠正肾衰患者由于血中肌酐、尿素氮升高造成的下丘脑功能障碍，且能恢复正常月经周期及生育力。     

Morbidity and mortality in liver retransplantation

INTRODUCTION: The incidence of orthotopic liver retransplantation (re-OLT) ranges from 6% to 11%. The most frequent causes of early re-OLT are allograft failure, uncontrolled acute rejection, and vascular complications. MATERIALS AND METHODS: A retrospective study of 512 orthotopic liver transplants (OLTs) in 482 patients over 15 years. RESULTS: The incidence of re-OLT was 6.6%, with a higher percentage of men requiring re-OLT than first-time OLT (75.0% vs 63.0%, P < .05). The reasons for re-OLT were thrombosis 21.7%, aneurysm 6.5%, stenosis 3.2%, primary nonfunction (PNF) 21.7%, and chronic rejection or recurrence of the initial disease 40.4%. Complications included PNF (22.0%), acute renal failure (65.6%), postoperative infection (87.5%), and adult respiratory distress syndrome (9.4%; P < .05). No differences were seen in the incidence of septicemia or postoperative hemorrhage. The average survival was much lower in re-OLT (21.8 days) compared with OLT (194.5 days; P < .05). The mortality rates in re-OLT were 100% for primary biliary cirrhosis, 85.7% for HCV, 50% for alcoholic cirrhosis, and 20% for HBV. A direct association between the Model for End-stage Liver Disease (MELD) score and the number of complications was present. DISCUSSION: There was a greater requirement for re-OLT in men and those patients transplanted due to hepatitis B virus cirrhosis and fulminant hepatitis (P < .05). The re-OLT patients had no greater incidence of sepsis compared with the OLT patients, although they did have a greater incidence of primary graft dysfunction, acute renal failure, adult respiratory distress syndrome, and postoperative infection (P < .05). The MELD was a good parameter for predicting graft evolution. Re-OLT in patients with primary biliary cirrhosis and hepatitis C virus was associated with a high degree of mortality.