肝移植术改善良性终末期肝病病人生存质量的初步研究

目的 研究肝移植手术对良性终末期肝病病人生存质量的改变情况。方法 采用WHOQOL-BREF表对29例良性终末期肝病病人在肝移植术前、术后1～3个月、术后4～6个月以及术后6个月以上4个时间段进行生存质量的测评。结果 良性终末期肝病病人在生理领域、自身生存质量总的主观感受及对自身健康状况总的主观感受方面，肝移植术后的评分与术前相比差异有统计学意义（P〈0．05）。结论 肝移植术可以提高良性终末期肝病受者的生存质量。     

肝移植术改善良性终末期肝病病人生存质量的初步研究

目的 探讨肝移植手术对良性终末期肝病病人生存质量的改变情况. 方法采用WHOQOL-BREF表对29例良性终末期肝病病人在肝移植术前、术后1～3个月,术后4～6个月以及术后6个月以上4个时间段进行生存质量的测评.结果 良性终末期肝病病人在生理领域、自身生存质量总的主观感受及对自身健康状况总的主观感受方面,肝移植术后的评分与术前相比差异有统计学意义(P＜0.05).结论 肝移植术可以提高良性终末期肝病受者的生存质量.     

肝移植治疗终末期肝病的单中心生存分析

目的 总结肝移植受者长期生存状态,探讨影响受者长期存活的因素.方法 对391例接受肝移植治疗的终末期肝病患者的临床资料进行回顾性分析.根据受者的基础疾病分类分别计算其存活率,并对随访期间原发疾病复发、死亡原因、并发症发生率及其病种和时间分布等资料进行分析,评价影响移植后原发疾病复发和并发症的相关因素.结果 进入随访期的受者共有331例,随访时间8～120个月.良性终末期肝病受者术后1、3、5和10年总体存活率分别为86%、85%、83%和83%,乙型肝炎病毒(HBV)相关肝硬化与重型肝炎受者术后长期存活率的差异无统计学意义(P＞0.05).符合米兰标准的肝癌患者术后1、3、5和10年存活率分别为96%、87%、87、%和87%,超出米兰标准的肝癌患者分别为42%、26%、24%和24%,二者间同期存活率的差异有统计学意义(P＜0.01).原发性肝癌患者肝移植后总体肿瘤复发率为54.3%,符合和超出米兰标准的肝癌患者肝移植后肿瘤复发率分别为4.3%和72.7%(P＜0.01),肿瘤复发是肝癌患者随访期主要的死亡原因,占所有死亡事件的95.5%.全组HBV再感染率为6.0%,且多存在HBV DNA的变异,调整抗病毒药物可有效控制HBV再感染.胆道并发症总体发生率为11.8%,肝内胆道狭窄为主要表现形式(占56.5%),严重影响移植肝功能及受者生存质量.钙调磷酸酶抑制剂相关性肾损害发生率为8.2%,早期发现和处理可避免进展为不可逆肾损害.结论 肝移植是治疗终末期肝病的安全、有效手段,在严格选择适应证、有序随访管理前提下,肝移植受者可长期存活,且存活质量良好.

Abstract：

Objective To investigate the survival condition of the liver transplant recipients and determine the factors which influence the long time survival. Methods Retrospective study of the follow-up data of the orthotopic liver transplantation recipients during 1999-2009 was performed.The survival rate of different primary disease was analyzed respectively. The recurrence of the primary disease, mortality and morbidity was also analyzed. Results 331 recipients were follwed up. The follow-up duration ranged from 8-120 months. The 1-, 3-, 5-, and 10-year survival rate of patients with benign end-stage liver disease was 86 %, 85 %, 83 %, and 83 %, respectively. There was no difference in the long- term survival rate between the patients with hepatitis B virus (HBV)-related cirrhosis and severe liver failure. The 1-, 3-, 5-, and 10-year survival rate of patients with HCC matching Millan criteria was 96 %, 87 %, 87 %, and 87 0%, while those of HCC exceeding Millan criteria were 42 % ,26 % ,24 % ,24 % resepectively. There was significant difference between them at the same period (P＜0. 01). The total recurrent rate of HCC recipient was 54. 3 %, and that of HCC matching and exceeding Millan criteria was 4.3 % and 72. 7 0% respectively (P＜0. 01 ). Tumor recurrence was the main cause of death of the malignancy. The HBV recurrent rate was 6. 0 0%, and all the cases were controlled by changing the antivirus regimen. The morbidity of billiary complication was 11.8 %, and intrahepatic biliary stricture was the most common type. CNIs-related renal impairment morbidity was 8. 2 % and the damage was reversible in condition of early diagnosis and treatment. Conclusion Orthotopic liver transplantation is an effective and safe treatment for end stage liver disease. The LTx recipients can get long time survival with perfect quallity life under proper medical supervision.     

活体肝移植治疗终末期肝病的研究进展

肝移植是治疗终末期肝病的有效治疗手段,为解决供体严重短缺的问题,在活体肝移植方面发展了新的手术技术,边缘供体已被用于活体肝移植以扩大供体库.     

终末期肝病模型对肝移植术后生存率的预测

目的探讨终末期肝病模型（model of end-stage liver disease，MELD）对良性终末期肝病肝移植患者生存率预测的价值。方法回顾性分析170例良性终末期肝病肝移植患者的临床资料，利用受试者工作特性曲线下面积（c-statistic值）评价MELD或Child-Turcotte-Pugh（CTP）评分预测患者肝移植术后生存时间的准确性。根据MELD值不同将患者分为3组：A组〈15，B组15～24和C组≥25，用Kaplan—Meier生存分析方法比较3组患者肝移植术后的生存率差别。结果MELD和CTP评分预测肝移植术后1、3、12个月生存率的c-statistic值分别为0．765和0．793、0．711和0．713、0．681和0．688。两者在同一时间的c-statistic值差异均无统计学意义。MELD评分与CTP评分有相关性（r=0．669，P=0．000）。A组和B组之间生存率差异无统计学意义（P=0．665），但C组生存率明显低于A组和B组，差异有统计学意义（分别为P=0．007和P=0．031）。结论MELD可以作为预测良性终末期肝病肝移植患者术后中、短期生存的指标，MELD≥25患者肝移植预后较差。MELD判断能力与CTP评分无明显差别。     

成人良性终末期肝病肝移植术后肾损伤部分危险因素分析

目的回顾性分析成人良性终末期肝病患者行原位肝移植术后发生肾损伤的部分危险因素。方法选择2014年5~12月于我院行同种异体原位肝移植的成人良性终末期肝病患者30例,男18例,女12例,年龄23~68岁,ASAⅢ或Ⅳ级。根据是否发生急性肾损伤(AKI),将患者分为:未发生AKI组(16例)与AKI组(14例)。收集资料包括术前一般情况、手术因素、麻醉因素、是否使用回收式自体输血、术后因素、患者术前肾功能、术后每日尿量、血肌酐(Scr)及尿素氮(BUN)。所有变量单因素分析P0.10纳入Logistic多元回归分析。结果与未发生AKI组比较,AKI组使用回收式自体输血明显减少,输注血小板明显增多,术后需使用升压药维持血压比例明显升高(P0.05)。使用回收式自体输血为保护性因素,OR值为0.058,95%CI为0.005~0.649;输注血小板为危险因素,OR值为10.706,95%CI为1.212~94.963。结论肝移植术使用回收式自体输血,合理输注血小板,可以减少AKI的发生;一旦患者术后需升压药维持血压,会增加AKI发生的可能性。     

活体肝移植治疗终末期肝病的研究进展

肝移植是治疗终末期肝病的有效治疗手段,为解决供体严重短缺的问题,在活体肝移植方面发展了新的手术技术,边缘供体已被用于活体肝移植以扩大供体库.     

活体肝移植治疗终末期肝病

目的 探讨活体肝移植(1iving donor liver transplantation,LDLT)供、受者术前评估和手术方式的选择.方法 回顾性分析1995年1月至2007年10月我中心95例LDLT患者的临床资料.良性终末期肝病92例,其中Wilson病45例;肝脏恶性肿瘤3例.结果 供肝切取不带肝中静脉右半肝31例,带肝中静脉右半肝3例,带肝中静脉左半肝51例,不带肝中静脉左半肝或左外叶10例.所有供者术后顺利恢复,均未出现严重并发症.受者随访1～86个月,良性终末期肝病受者1、3、5年累积生存率分别为89%(82例)、78%(71例)和73%(67例),其中Wilson病受者1、3、5年累积生存率分别为92%(42例)、89%(40例)和76%(34例).3例肝脏恶性肿瘤患者死亡2例,1例长期生存.供、受者铜代谢均恢复正常.结论 建立供者安全保障体系是LDLT开展的先决条件,选择合理的手术方式是提高受者生存率的关键.亲体肝移植是治疗Wilson病的有效手段.     

终末期肝病模型对肝移植病人的预后分析

目的 探讨终末期肝病模型(MELD)对肝移植病人早期生存率的预测价值.方法 92例肝移植病人进行回顾性分析,通过受试者特征曲线(ROC),计算Youden指数判定ROC曲线的截断值,根据截断值,制作Kaplan-Meier生存曲线,利用生存曲线分析MELD评分对肝移植术后3个月预后判断的准确性.结果 随访3个月内累计死亡8人,3个月死亡组和生存组MELD积分分别为24.88士11.97,16.11±10.81(P<0.05).MELD积分系统对肝移植术后3个月预后判断的截断值为16,生存曲线分析表明MELD评分能有效地区分可能死亡和可能存活的病人,并且证实MELD评分系统能够有效预测肝移植术后3个月生存、死亡可能性.结论 MELD评分系统可有效地预测肝移植病人的短期预后效果.     

Results of treatment in patients with end-stage renal disease: a multivariate analysis of risk factors and survival in 341 successive patients

Factors that affect survival in patients with end-stage renal disease (ESRD) are still only partially understood. We report an analysis on a cohort of 341 successive patients who started ESRD treatment in one institution. Survival was calculated from the start of ESRD treatment, whether initial treatment was by dialysis (335 patients) or transplantation (6 patients). Analysis of factors affecting survival was done using the Cox multivariate hazard analysis. Relative risks were calculated for several demographic factors, the primary renal disease, the presence or absence of various high-risk co-morbid factors, and for a first transplant from a living-related or cadaver donor. Older patients, patients with no prior health insurance, those with diabetic nephropathy, and those with small kidneys of unknown cause had statistically significantly higher risks of dying. The risk of dying decreased by year of start of ESRD treatment. Living related donor transplantation was associated with a decreased hazard to age 45 years and older; whereas cadaver donor transplantation was associated with a hazard that increased with age and was significantly increased by age 45.     

术前门静脉血栓对终末期肝硬化患者行肝移植手术的影响

目的  探讨术前门静脉血栓对终末期肝硬化患者行肝移植的影响。方法  回顾性分析2007年1月至2011年12月在中山大学附属第三医院器官移植中心接受肝移植手术的182例终末期肝硬化患者的临床资料。将合并门静脉血栓的13例(Yerdel分级Ⅰ级3例, Ⅱ级6例, Ⅲ级2例, Ⅳ级2例)患者作为门静脉血栓组, 其余169例无门静脉血栓的患者作为对照组。比较两组患者肝移植术中和术后情况。结果  与对照组比较, 门静脉血栓组的手术时间和术中出血量较多(均为P < 0.05), Ⅲ~Ⅳ级血栓者的手术时间和术中出血量亦较多(均为P < 0.05)。术后1个月, 门静脉血栓组发生门静脉血栓1例(8%), 对照组发生3例(2%), 两组比较差异有统计学意义(P < 0.05)。门静脉血栓组术后3年存活率为46%(6/13), 对照组相应为84%(142/169), 两组比较差异有统计学意义(P < 0.05)。结论  Ⅲ~Ⅳ级门静脉血栓会明显增加肝移植手术难度和风险, 但只要术前严格评估门静脉血栓情况, 术中采用合理的门静脉重建方式, 依然可以取得良好的疗效。     

Isolated liver and multivisceral transplantation for total parenteral nutrition-related end-stage liver disease

Purpose

Total parenteral nutrition (TPN) has prolonged survival in children with intestinal failure; however, end-stage liver disease owing to TPN-induced cholestasis (ESLD-TPN) may preclude its use. ESLD-TPN is an indication for isolated liver transplantation (ILT) or multivisceral transplantation (MVT). Isolated liver transplantation for ESLD-TPN should only be considered in patients who have the potential for enteral autonomy.

Methods

We retrospectively reviewed the records of patients with ESLD-TPN who underwent ILT (n = 7) or MVT (n = 5) between 1994 and 2005. The median age at the time of transplantation was 10.0 months. Intestinal failure followed necrotizing enterocolitis (n = 3), gastroschisis (n = 3), gastroschisis with volvulus (n = 3), gastroschisis with atresia (n = 1), malrotation (n = 1), and megacystis microcolon intestinal hypoperistalsis syndrome (n = 1).

Results

Isolated liver transplant patients had a median length of small bowel of 70 cm and tolerated a median of 50% of enteral calories. The median length of small bowel in patients who underwent MVT was 29 cm, and none tolerated more than 30% of goal enteral feeds. Reduced-size (n = 5) and whole-liver (n = 2) allografts were used for patients undergoing ILT. Patients undergoing MVT received liver-small bowel-pancreas (n = 4) or liver-small bowel-pancreas-colon (n = 1). Overall patient survival was 57% in ILT (median follow-up = 25.1 months); 3 survivors are TPN independent, and the fourth patient requires TPN 3 days/wk. Patient survival was 40% after MVT (median follow-up = 13.0 months); 1 MVT patient died of abuse 16.9 months after transplant and was TPN independent at the time of death. Both survivors are TPN independent. Bilirubin levels are within normal range in all survivors.

Conclusion

Isolated liver transplantation for ESLD-TPN in the setting of intestinal failure is a viable option in patients who have the potential for enteral autonomy. Multivisceral transplantation is the only alternative in patients without the potential for intestinal recovery. Survival can be achieved in patients with ESLD-TPN, but mortality remains high for both procedures.     

良性重症终末期肝病肝移植术后免疫抑制剂治疗179例分析

目的：总结良性重症终末期肝病肝移植术后免疫抑制剂的应用经验,探讨个体化用药方案的价值。方法：回顾分析2002年4月—2010年8月术前终末期肝病模型（MELD）评分≥25分的179例肝移植病例资料,分为3个阶段：第一阶段（2002年4月—2004年12月）65例,第二阶段（2005年1月—2007年12月）64例,第三阶段（2008年1月—2010年8月）50例。第一阶段采用他克莫司（Tac）＋吗替麦考酚酯（MMF）＋甲基强的松龙（MP）的常规三联用药方案,第二阶段采用减量的三联用药方案,第三阶段采用个体化免疫抑制方案。比较3个阶段存活率、感染死亡率和排斥反应发生率。结果：第一、第二、第三阶段患者的存活率呈逐渐升高的趋势;患者感染死亡病例数占相应阶段病例总数比率为27.7%、17.2%、8.0%,差异有统计学意义（P〈0.05）;患者感染死亡病例数占相应阶段死亡病例数比率为85.7%、64.7%、44.4%,呈下降趋势,第三阶段与第一阶段比较,差异有统计学意义（P〈0.05）;第三阶段与第二阶段排斥反应发生率差异无统计学意义（P〉0.05）,与第一阶段比较排斥反应发生率虽然轻度升高（P〈0.05）,但是存活率却由67.7%提高到82.0%。结论：良性重症终末期肝病肝移植术后免疫抑制剂的个体化应用,减少了用药量,降低了感染死亡率,有利于提高患者存活率。     

门静脉血栓对终末期肝硬化病人行肝移植手术的影响

目的探讨合并门静脉血栓(portal vein thrombosis,PVT)的终末期肝硬化病人行肝移植手术的处理方法及其疗效。方法回顾性分析2010年1月至2015年12月在中山大学附属第一医院器官移植中心接受肝移植手术的152例终末期肝硬化病人的临床资料。32例合并PVT的病人作为PVT组,其中Ⅰ级10例、Ⅱ级13例、Ⅲ级8例、Ⅳ级1例。其余120例无PVT的病人作为对照组。结果PV/T组术前脾切除史的比例明显高于对照组(46.8%比18.3%,P0.05),差异有统计学意义。PVT组较对照组明显延长无肝期时间[(72.5±25.3)min比(57.6±18.4)min,P0.05]和总手术时间[(622.4±183.5)min比(503.2±123.6)min],差异均有统计学意义。2组病人在术中出血量、ICU住院时间、术后并发症发生率、围手术期病死率、1年及3年生存率的比较上差异均无统计学意义(P0.05)。PVT组术后再栓塞率高于对照组(9.4%比1.7%,P0.05)。结论门静脉血栓一定程度上增加了终末期肝硬化病人肝移植手术的难度,Ⅰ~Ⅲ级PVT不影响病人的预后,仍可通过肝移植手术取得良好的疗效。Ⅳ级PVT肝移植手术的难度和风险会明显增加,应谨慎对待。     

APACHEII模式联合MELD评分在预测活体肝移植围手术期预后中的作用

目的探讨APACHE(急性生理学和慢性健康评分)II模式联合MELD(终末期肝病模型)评分如何准确地评估活体肝移植围手术期预后。方法总结2006年6月至2009年5月在上海交通大学附属瑞金医院行活体肝移植术38例病人临床资料。结果围手术期存活组与死亡组病人的APACHE II分值分别为13.03±3.47和23.67±3.27;死亡风险度分别为(7.05±3.70)%和(25.07±9.34)%。两组病人的APACHE II分值、死亡风险度差异具统计学意义(P<0.001)。排除外科因素后APACHE II模式对预后的评估具有更好的准确性。MELD>25分与MELD<25分的病人预期病死率分别为(7.10±3.84)%和(15.11±11.93)%,差异具统计学意义(P<0.05)。APACHE II评分和MELD评分的接受者操作特征曲线(ROC)界值分别为20分和25分。结论应用APACHE模式对活体肝移植进行评估时应注意避免外科因素干扰;校正后APACHE II模式预测准确性更佳;APACHE II>20分或MELD>25分的病人预期病死率则显著增高。     

Growth failure,risk of hospitalization and death for children with end-stage renal disease

Growth failure remains a significant problem for children with chronic renal insufficiency and end-stage renal disease (ESRD). We examined whether growth failure is associated with more-frequent hospitalizations or higher mortality in children with kidney disease. We studied data on prevalent United States pediatric patients with ESRD in 1990 who were followed through 1995. Patients were categorized according to the standard deviation score (SDS) of their incremental growth during 1990: severe (<–3 SDS), moderate growth failure (>–3 and <–2 SDS), and normal growth (>–2 SDS). Among 1,112 prevalent pediatric dialysis and transplant patients (<17 years, Tanner I–IV), those with severe and moderate growth failure had higher hospitalization rates {relative risk (RR) 1.14 [95% confidence interval (CI) 1.1, 1.2] and 1.24 [95% CI 1.2, 1.3]} respectively than those with normal growth after adjustment for age, gender, race, cause and duration of ESRD, and treatment modality (dialysis or transplant) in 1990. Kaplan-Meier survival analysis showed 5-year survival of 85% and 90% for patients with severe and moderate growth failure, respectively, compared with 96% for patients with normal growth (P<0.001, log-rank). Cox proportional hazards analysis revealed that those with severe (RR 2.9, 95% CI 1.6, 5.3) and moderate growth failure (RR 2.01, 95% CI 1.1, 3.6) had an increased risk of death compared with youths with normal growth, after adjustment. A higher proportion of deaths in the severe and moderate growth failure groups were attributed to infectious causes (22% and 18.7%, respectively) than in the normal growth group (15.6%). We conclude that growth failure is associated with a more-complicated clinical course and increased risk of death for children with kidney failure. Received: 15 August 2001 / Revised: 14 January 2002 / Accepted: 15 January 2002