肝移植术后急性肺损伤的危险因素

目的研究肝移植术后发生急性肺损伤（Acute lung injury，ALI）的危险因素。方法回顾性分析100例终末期肝病患者肝移植术后的临床资料。进行单因素及多因素回归分析肝移植术后发生ALI的危险因素。结果13例患者（13％，13／100例）被诊断为肝移植术后ALI。logistic回归分析显示术中大量输血（输血量超过5000ml）和严重的再灌注损伤（血清丙氨酸转氨酶超过600U／L）是肝移植术后急性肺损伤的独立危险因素。术中大量输血的患者发生ALI的危险增加12．7倍；严重的再灌注损伤发生ALI的危险增加7．0倍。结论大量输血和再灌注损伤是肝移植术后发生ALI的两个重要危险因素。ALI是肝移植术后严重的多因素并发症，有很高的死亡率。     

肝移植术后急性肺损伤/急性呼吸窘迫综合征的研究进展

急性肺损伤/急性呼吸窘迫综合症（ALI/ARDS）是肝移植术后常见的并发症,可延长受者术后重症监护室入住时间,影响肝移植手术疗效,病情严重可致受者死亡,临床中引起了肝移植外科医师的高度重视。肝移植术后ALI/ARDS可由肺源性因素（例如机械通气相关肺损伤、肺部感染、误吸等）直接导致,也可由非肺源性因素（例如肺部以外的严重感染、输血、缺血-再灌注损伤等）间接导致。本文对肝移植术后ALI/ARDS的诊断标准及发生情况、发生机制、危险因素、实验室及临床诊断方法以及治疗方法等进行综述,加深对肝移植围手术期ALI/ARDS的理解与认知,以期为肝移植术后ALI/ARDS的诊治提供借鉴。     

重症急性胰腺炎并发急性肺损伤危险因素的临床研究

目的探讨重症急性胰腺炎(SAP)患者急性期急性肺损伤(ALI)的危险因素。方法对2008年1月至2011年12月107例SAP患者进行回顾性分析,观察其不同CT分级、入院24 h内生理学指标、急性生理学与慢性健康状况Ⅱ(APACHEⅡ)评分以及全身炎症反应综合征(SIRS)持续时间与肺损伤的相关性,并采用单因素x2检验及非条件多因素Logistic回归分析导致肺损伤的危险因素。结果 107例SAP患者并发ALI 39例,其中发生ARDS 16例。ALI/ARDS的发生与SAP的病因、病史时间、CT分级、SIRS、APACHEⅡ分值、Ca2+浓度、白蛋白浓度(ALB)、血糖浓度(GLU)、白细胞计数(WBC)及中性粒细胞计数(PMN)明显相关。进入非条件多因素Logistic回归分析的因素有白蛋白浓度、Ca2+浓度以及SIRS。结论本组资料SAP的ALI/ARDS发病率为36.45%,白蛋白浓度、Ca2+浓度及SIRS是SAP并发ALI的独立危险因素。     

肝移植术后急性肺损伤的危险因素分析

目的 总结62例肝移植患者的临床资料，回顾性分析术后急性肺损伤（acute lung injury，ALI）发生的危险因素。方法 按ALI的诊断标准，将62例患者分为急性肺损伤组（ALI组）和非急性肺损伤组（NO—ALI组），比较两组的年龄、性别、原发病因、手术方式及预后。单因素、Logistic回归分析肝移植术后ALI发生的危险因素。结果 两组患者年龄、性别、原发病因及手术方式无明显差别。12例ALI发生在术后1d至4周，3例死亡。单因素分析发现，术后肺部感染、术中及术后的门肺高压、术中输血量、术中补液量、术后再次开腹、术后急性肾功能衰竭、术后激素冲击治疗对ALI的发生有显著影响。回归分析提示，术后肺部感染、术中及术后的门肺高压是ALI发生的危险因素。结论 术后肺部感染、术中及术后的门肺高压是肝移植术后ALI发生的危险因素，重视上述因素对预防与减少ALI的发生具有较重要的临床意义。     

肝癌肝切除术后ALI和ARDS的诊治

目的探讨肝切除术后急性肺损伤(ALI)、急性呼吸窘迫综合征(ARDS)的诊断、治疗和预防方法。方法总结3年间516例肝癌肝切除术后发生急性肺损伤和急性呼吸窘迫综合征9例病人的临床资料，包括诱发因素，术后呼吸频率、SpO2、PaO2／FiO2、血气分析和X线胸片。治疗为面罩给氧、激素等控制炎症反应药物、严格限制液体量、沐舒坦和雾化吸入维持呼吸道通畅。密切观察病情变化，一旦ARDS诊断成立尽早应用呼吸机PEEP治疗。结果9例病人有7例符合ALI的诊断，2例符合ARDS诊断，全部救治成功。结论ALI和ARDS是肝切除术后严重并发症。术中低血压过程和大量输血、胃内容物误吸、高龄患者合并肺部感染为3个主要诱因；SpO2监测有利于早期诊断ALI与ARDS；早期发现、及早救治可获得满意效果。     

肝移植围手术期肺部并发症的危险因素及相关防治

背景 肝移植围手术期各类肺部并发症发生率高,发病机制复杂,严重影响患者的预后.目的 分析肝移植围手术期肺部并发症的危险因素并提出具体防治措施以保护肺功能.内容 介绍肝移植术后急性肺损伤(acute lung injury,ALI)的机理；患者术前病理生理因素、麻醉因素以及非特异性因素与肺部并发症的关系；围手术期肺功能保护的措施.趋向 对相关机制和危险因素进行深入研究,并采取相应防治措施,有助于减少肝移植患者围手术期肺部并发症的发生.     

腹部外科术后急性肺损伤及其治疗策略

急性肺损伤（ALI）是多种原因引起的早期急性呼吸衰竭症候群，也是外科病人术后较为常见的并发症。据统计手术后肺部并发症（postoperative pulmonary complications，PPC）发生率可达约30％。外科术后患者除了原发疾病的打击外，常常还存在麻醉、疼痛、创伤、感染、大量输血、误吸、炎性反应综合征（SIRS）等影响，如果处理不当，这些危险因素往往可以诱发急性肺损伤甚至ARDS，其病死率较高。     

肝切除术后急性肺损伤和呼吸窘迫综合征的诊治

我科于2000年1月至2003年1月共行原发性肝癌肝切除术516例，术后发生急性肺损伤(acute lung injury，ALI)7例，急性呼吸窘迫综合征(ARDS)2例。发生率为1．74％(9／516)。现统计分析9例临床病例资料，以了解其发病规律，总结肝切除术后ALI和ARDS的预防和治疗体会。     

原位肝移植术后并发症的诊治体会(附16例报告)

目的 探讨原位肝移植术后并发症的诊治经验。方法 回顾性分析我院16例肝病患者行17例次肝移植术后各种并发症的诊断及治疗方法。结果 全组手术成功12例次，围手术期死亡5例，死亡原因：脑出血1例，急性呼吸窘迫综合征(ARDS)1例，急性肾功能衰竭1例，肝动脉血栓1例，急性排斥反应1例。现存活6例，其中1例存活已超过3年。术后并发腹腔内出血3例，脑血管病变2例，ARDS2例，血管并发症2例，胆道并发症3例，急、慢性排斥反应各2例，急性肾功能衰竭2例。结论 肝移植围手术期采取合理的防治措施能有效地减少肝移植术后并发症的发生，对肝移植术后并发症的及时诊断和有效治疗是提高肝移植术后成功率的关键．     

急性胰腺炎并发ALI及ARDS的机制

急性胰腺炎发病急骤,病情变化迅速,可并发急性肺损伤(ALI)及急性呼吸窘迫综合征(ARDS),甚至发生多器官功能障碍综合征,病死率一直居高不下.急性胰腺炎并发ALI及ARDS的机制错综复杂,涉及炎症反应失控、细胞的损伤与凋亡、胰酶的作用、凝血与纤溶失衡等多个层面,而这些层面彼此相互关联形成复杂的网络.深入探讨急性胰腺炎并发ALI及ARDS的机制,将为临床诊治提供更多新的作用靶点.     

肝移植术后患者并发急性肺损伤与术中氧代谢的关系

目的 研究肝移植术后患者并发急性肺损伤(ALI)与术中氧代谢的关系.方法 择期行肝移植术的终末期肝病患者62例,年龄29～63岁,体重48～76 kg,ASA Ⅲ或Ⅳ级.于麻醉诱导后(T1)、无肝期前10 min(T2)、无肝期25 min(T3)、新肝期30 min(T4)及术毕(T5)时,采集桡动脉血和混合静脉血进行血气分析,计算动脉血氧含量(CaO2)、混合静脉血氧含量(C(v)O2)、动脉-混合静脉血氧含量差(Ca-(v)O2)、氧供指数(DO2I)、氧耗指数(VO2I)、氧摄取率(ERO2)和通气.血流灌注指数(VQI).根据术后14 d内是否发生ALI分为2组:ALI组和非ALI组.两组氧代谢指标与术后ALI发生与否进行logistic回归分析.结果 与T1时相比,T2,4,5时P(v)O2升高,T3时降低,T2-5时CaO2、C(v)O2升高,T3时Ca-(v)O2升高,T2,4,5时DO2I、VO2I升高,ERO2降低,T3时VQI降低,氧合指数T3时降低,T4时升高(P<0.05).与非ALI组相比,ALI组T4,5时CaO2、C(v)O2和DO2I降低,T1,2,4,5时PaO2降低(P＜0.05).logistic回归分析结果示T4时PaO2和T5时CaO2与术后发生ALI有关(P<0.05).结论 肝移植术后患者并发ALI可能与新肝期氧代谢异常有关.     

Inflammatory Bowel Disease After Liver Transplantation: Risk Factors for Recurrence and De Novo Disease

Inflammatory bowel disease (IBD) is associated with primary sclerosing cholangitis (PSC) and autoimmune hepatitis (AIH) and can recur or develop de novo after orthotopic liver transplantation (OLT). The aim of this study was to investigate the incidence and severity of IBD after liver transplantation and to perform a multivariate analysis for possible risk factors. In this retrospective study, 91 patients transplanted for PSC or AIH, without prior colectomy, were included. Sixty patients were transplanted for PSC, 31 for AIH. IBD activity before and after OLT and other possible risk factors were analysed in a multivariate model. Forty-nine patients (54%) had IBD before OLT. Forty patients (44%) had active IBD after transplantation: recurrence in 32 and de novo in 8. Cumulative risk for IBD after OLT was 15, 39 and 54% after 1, 5 and 10 years, respectively. In 59% of patients with IBD prior to OLT the disease was more active after transplantation. Risk factors for recurrent disease were: symptoms at time of OLT, short interval of IBD before OLT and use of tacrolimus. 5-aminosalicylates were protective. A cytomegalovirus positive donor/negative recipient combination increased the risk for de novo IBD.     

肝移植后脑病围手术期危险因素分析

目的分析肝移植术后脑病发生的危险因素,为预防提供思路。方法观察并追踪240例肝移植受者,统计分析不同原发病、Child-Turcotte-Pugh(CTP)分级、终末期肝病模型(MELD)评分患者术后脑病的发生率,并根据脑病发生与否分为脑病组和非脑病组,分析两组间术前、术中及术后相关因素的差异。结果 240例肝移植患者中57例(23.7%)术后出现了脑病症状,其中表现为焦虑不安27例、谵妄13例、妄想8例、抽搐7例、听觉障碍2例。Logistic回归分析结果显示术前凝血酶原时间18s和术后血肌酐浓度大于正常参考值是肝移植术后脑病发生的主要危险因素。结论肝移植后脑病的发生与多种因素有关,其中术前凝血酶原时间在18s以上和术后血肌酐浓度大于正常参考值是最重要的危险因素。     

Herpes zoster infection after liver transplantation: a case-control study.

Prior case series have suggested that herpes zoster (HZ) after orthotopic liver transplantation (OLT) may lead to serious complications due to visceral involvement. We sought to determine the incidence, risk factors, and long term outcomes of HZ after OLT. Clinical data from September 1993 to April 2004 were collected on all cases of HZ after OLT, and at the same post-OLT time points in age, gender, and transplant-year-matched HZ-negative controls. Risk factors for HZ infection and long-term outcomes were compared between cases and controls. A total of 29 patients developed HZ at a median of 4.9 years (range .5-12.9) after OLT. All HZ infections except 1 were localized to a single dermatome. Only 8 (28%) were hospitalized and 16 (55%) were treated with oral antivirals alone. No patients developed visceral involvement or died of HZ infection. No risk factors for HZ infection were identified on multivariate analysis. Of the long-term outcomes, the estimated 10-year survival was lower (P = .05) for cases than controls. The lower survival in HZ cases was not directly attributable to HZ infection. In conclusion, this study is the largest series on HZ after OLT. HZ is neither a common nor a serious infection after OLT and can be managed with antiviral therapy with a low likelihood of visceral dissemination.     

Incidence and risk factors for the development of prolonged and severe intrahepatic cholestasis after liver transplantation.

Predictive factors for intrahepatic cholestasis after orthotopic liver transplantation (OLT) have not yet been established. We sought to identify the incidence and risk factors associated with prolonged severe intrahepatic cholestasis (PSIC) after OLT. We assessed 428 consecutive patients undergoing their first OLT. PSIC was diagnosed if a serum bilirubin concentration was greater than 100 micromol/L and/or a 3-fold increase of alkaline phosphatase occurred within the first month after OLT and was sustained for at least 1 week in the absence of biliary complications. Multivariable logistic regression identified factors independently associated with PSIC. PSIC developed in 107 patients (25%). Independent risk factors by multivariable analysis were intraoperative transfusion of cryoprecipitate and platelets; nonidentical blood group status; suboptimal organ appearance; inpatient status before transplantation; and bacteraemia in the first month after transplantation. In contrast, acute liver failure, older age, and higher levels of serum sodium and serum potassium were all associated with a reduced likelihood of developing PSIC in the first month. There were 47 deaths in the PSIC group (44%) as opposed to 65 deaths in the non-PSIC group (20%) after OLT. A poor preoperative clinical status in conjunction with a suboptimal graft was associated with PSIC after OLT. Avoidance of suboptimal livers and ABO nonidentical grafts for young patients with poor synthetic function and for pretransplant inpatients may lessen this complication and reduce the associated early mortality.     

Right subcostal incision in liver transplantation: prospective study of feasibility

Little is known about incidence and risk factors for incisional hernia after liver transplantation (OLT). More frequently this problem occurs at the junction of midline and transverse incisions. We prospectively and consecutively used three different types of abdominal incisions in 47 OLTs. The results were compared in order to identify the type of incision and risk factors that determine herniae after OLT. The overall incidence was 17%. It occurred in 6 out of 19 patients (31.3%) with a transverse and right subcostal both with upper midline incision versus 2 out of 26 patients (7.7%) with only a right subcostal incision. In conclusion, a subcostal incision is sufficient to perform OLT and reduce hernia incidence after OLT.     

Nonanastomotic biliary strictures after liver transplantation, part 1: Radiological features and risk factors for early vs. late presentation.

Nonanastomotic biliary strictures (NAS) are a serious complication after orthotopic liver transplantation (OLT). The exact pathogenesis is unclear. Purpose of this study was to identify risk factors for the development of NAS after OLT. A total of 487 adult liver transplants with a median follow-up of 7.9 years were studied. All imaging studies of the biliary tree were reviewed. Cholangiography was routinely performed between postoperative days 10-14 and later on demand. Localization of NAS at first presentation was categorized into 4 anatomical zones of the biliary tree. Severity of NAS was semiquantified as mild, moderate, or severe. Donor, recipient, and surgical characteristics and variables were analyzed to identify risk factors for NAS. NAS developed in 81 livers (16.6%). Thirty-seven (7.3%) were graded as moderate to severe. In 85% of the cases, anatomical localization of NAS was around or below the bifurcation of the common bile duct. A large variation was observed in the time interval between OLT and first presentation of NAS (median 4.1 months; range 0.3-155 months). NAS presenting early (< or =1 year) after OLT were associated with preservation-related risk factors. Cold and warm ischemia times were significantly longer in patients with early NAS compared with NAS presenting late (>1 year) after OLT (694 minutes vs. 490 minutes, P = 0.01, and 57 minutes vs. 53 minutes, P < 0.05, respectively), and early NAS were more frequently located in the central bile ducts. NAS presenting late (>1 year) after OLT were found more frequently in the periphery of the liver and were more frequently associated with immunological factors, such as primary sclerosing cholangitis, as the indication for OLT (24% vs. 45%, P < 0.05). By separating cases of NAS on the basis of the time of presentation after transplantation, we were able to identify differences in risk factors, indicating different pathogenic mechanisms depending on the time of initial presentation.     

Cumulative risk of cardiovascular events after orthotopic liver transplantation

As survival after orthotopic liver transplantation (OLT) improves, cardiovascular (CV) disease has emerged as the leading cause of non-graft-related deaths. The aims of our study were to determine the cumulative risk of CV events after OLT and to analyze predictive risk factors for those experiencing a CV event after OLT. We identified all adult patients who underwent OLT at our institution for end-stage liver disease between October 1996 and July 2008. The cumulative risk of CV events after OLT was analyzed with the Kaplan-Meier method. Multivariate logistic regression analysis was used to identify factors independently associated with CV events after OLT. In all, 775 patients were included in our study cohort (mean age of 53.3 years, female proportion = 44%, Caucasian proportion = 84%, median follow-up = 40 months). The most common indications for OLT were hepatitis C virus (33.2%), alcohol (14.5%), and cryptogenic cirrhosis (12.7%). Eighty-three patients suffered 1 or more CV events after OLT. Posttransplant metabolic syndrome was more prevalent in patients with CV events versus patients with no CV events (61.4% versus 34.1%, P < 0.001). According to a multivariate analysis, independent predictors of CV events were an older age at transplantation [odds ratio (OR) = 1.2, addition of 95% confidence interval (CI) = 1.1-1.3, P = 0.006], male sex (OR = 2.0, 95% CI = 1.2-3.3, P = 0.01), posttransplant diabetes (OR = 2.0, 95% CI = 1.3-3.3, P = 0.003), posttransplant hypertension (OR = 1.8, 95% CI = 1.1-3.0, P = 0.02), and mycophenolate mofetil (OR = 2.0, 95% CI = 1.3-3.2, P = 0.003). Among post-OLT patients, the cumulative risk at 5 years of 13.5%, respectively. In conclusion, cardiac complications after liver transplantation are common (Approximately 10% of patients experience 1 or move cv events). Patients with posttransplant hypertension and diabetes, which are modifiable risk factors, are approximately twice as likely to experience a CV event.     

Colonization with methicillin-resistant Staphylococcus aureus after liver transplantation.

Methicillin-resistant Staphylococcus aureus (MRSA) is a frequent cause of infection after orthotopic liver transplantation (OLT). Colonization with MRSA is associated with a higher risk of infection. Previous studies have shown a high prevalence of MRSA colonization among OLT candidates. However, the risk of colonization with MRSA after OLT is still unclear. The objective of this study was to estimate the incidence and the factors associated with colonization with MRSA after OLT. This was a prospective cohort study including patients submitted to OLT between the years 2000 and 2002. Surveillance cultures of nasal swab specimens were performed within the 1st 72 hours of hospital admission and, subsequently, on weeks 2, 6, 13, and 26. Patients whose baseline cultures revealed nasal carriage of MRSA were excluded. A total of 60 patients were included in the study. The median follow-up was 72 days. A total of 9 patients (15%) became colonized. In multiple logistic regression analyses, the use of a urinary catheter for > or =5 days (P = .006), postoperative bleeding at the surgical site (P = .009), and preoperative use of fluoroquinolones (P = .08) were associated with a higher risk of colonization. Patients without any of these risk factors did not become colonized. In conclusion, nasal carriage of MRSA is frequently acquired after OLT. Periodic postoperative screening for MRSA carriage should be an integral component in programs designed to reduce nosocomial MRSA transmission in these patients. Further studies are needed to set up and validate a predictive model that could allow targeting postoperative screening to high-risk OLT recipients.