肝移植术后急性肾功能衰竭七例的防治

目的探讨同种异体原位肝移植术后急性肾功能衰竭的防治。方法回顾性分析5 1例肝移植的临床资料 ,总结肝移植术后急性肾功能衰竭的防治体会。结果 5 1例患者中 ,有 9例术前已存在不同程度的肾功能损害 (Cr≥ 132 μmol/L或BUN≥ 18μmol/L) ;其中 7例患者在术后 1周内并发了急性肾功能衰竭 ,术后选择了将赛尼哌加入常规的免疫抑制剂方案中作为免疫诱导 ,同时积极应用多巴胺等血管活性药物改善肾脏灌注 ;6例肾功能在 3～ 6d内得到纠正 ,1例患者经上述治疗效果欠佳 ,采用了无肝素血液透析 ,术后第 11天肾功能亦得到恢复。结论肝移植术后急性肾功能衰竭诱发因素众多 ;术后注意免疫抑制剂的个体化应用 ,积极改善肾脏灌注 ,必要时选择血液透析治疗 ,多数患者的肾功能能够得到恢复。     

肝移植术后急性肾功能衰竭的预防和治疗

目的总结肝移植术后急性肾功能衰竭的预防和治疗经验。方法回顾性分析63例原位肝移植术后早期发生急性肾功能衰竭患者的临床资料,探讨其发病的危险因素及治疗方法。结果63例患者中,12例术前已存在不同程度的肾功能损害,28例有严重的腹水及进行性高胆红素血症。术后发生肺部感染28例,多器官功能衰竭26例,腹腔内积液、积脓9例。所有患者肝移植术后均采用环孢素A、霉酚酸酯或他克莫司预防排斥反应。23例患者应用多巴胺(2-5μg·kg-1·min-1)等血管活性药物改善肾脏灌注,并酌情配合利尿药物的使用,同时给予白蛋白、新鲜血浆输注、营养支持及抗感染治疗。12例病情较重者给予持续性肾脏替代治疗(CRRT),平均治疗时间50 h。术后1个月时,有26例患者死亡,死亡率为41．27％。结论肝移植术前应重视对肾功能的评估并及时处理,术后尽量避免感染。免疫抑制剂的个体化应用,改善肾脏灌注,可提高肝移植术后急性肾功能衰竭治疗的成功率。     

肝移植病人术后急性肾功能衰竭18例临床分析

目的:探讨影响肝移植术后发生急性肾功能衰竭的原因及处理方法。方法:回顾性分析我院91例肝移植病人中发生与未发生术后急性肾功能衰竭病人的临床资料,采用单因素分析和Logistic回归模型进行多因素分析。结果:肾衰组病人1年生存率低于对照组;与术后发生早期急性肾功能衰竭的有关因素包括术前血清肌酐、总胆红素、总手术时间、术中出血量、输血量、术中输液总量、术中尿量。术前血清肌酐高和术中尿量是术后早期急性肾功能衰竭发生的独立影响因素。移植术后发生急性肾功能衰竭的病人ICU留置时间延长,术后住院时间延长,住院费用升高。结论:肝移植术后有较高的急性肾功能衰竭发生率,对术后少尿、血清肌酐水平升高的病人及早实施肾脏替代等治疗能有效降低其发病率和死亡率。     

肝移植术后早期急性肾功能衰竭的诊断和治疗(附41例回顾性分析)

目的总结肝移植术后早期急性肾功能衰竭的防治经验。方法回顾性分析41例肝移植术后早期肾功能不全的发病机制、治疗方法及效果。结果41例肝移植受者中,死亡14例(34.15%)。术后并发症:肺部感染24例,多器官功能障碍综合征(MODS)13例,腹腔出血6例,急性排斥反应6例,胆道并发症3例,门静脉血栓1例,原发性移植肝无功能1例,全身播散性真菌感染1例。术后2例生存超过5年,4例生存超过4年,7例生存超过3年,11例生存超过2年。结论在背驮式肝移植中行腔-腔静脉侧侧吻合(SSCCA)、采用抗CD25单克隆抗体诱导治疗、降低钙神经蛋白抑制剂用量、实施环孢素C2监测对降低肝移植术后早期急性肾功能衰竭的发生率可能有一定意义,对于出现难以逆转的肾损害同时无法耐受血液透析的受者,肾移植可能是惟一的选择。     

肝移植术后早期急性肾功能衰竭的诊断和治疗（附41例回顾性分析）

目的 总结肝移植术后早期急性肾功能衰竭的防治经验。方法 回顾性分析41例肝移植术后早期肾功能不全的发病机制、治疗方法及效果。结果 41例肝移植受者中，死亡14例（34．15％）。术后并发症：肺部感染24例，多器官功能障碍综合征（MODS）13例，腹腔出血6例，急性排斥反应6例，胆道并发症3例，门静脉血栓1例，原发性移植肝无功能1例，全身播散性真菌感染1例。术后2例生存超过5年，4例生存超过4年，7例生存超过3年，11例生存超过2年。结论 在背驮式肝移植中行腔-腔静脉侧侧吻合（SSCCA）、采用抗CD25单克隆抗体诱导治疗、降低钙神经蛋白抑制剂用量、实施环孢素C2监测对降低肝移植术后早期急性肾功能衰竭的发生率可能有一定意义，对于出现难以逆转的肾损害同时无法耐受血液透析的受者，肾移植可能是惟一的选择。     

肾缺血再灌注损伤的介导因素

缺血和缺氧后急性肾功能衰竭的发病机制一直是国内外研究的焦点,目前认为缺血后再灌注早期肾脏病理生理过程是影响急性肾功能衰竭发生、发展和预后的关键,本文综述了缺血再灌注早期肾损伤的介导因素和防治措施的最新进展。     

肝移植术后早期急性肾功能衰竭处理及危险因素分析

目的探讨肝移植术后早期急性肾功能衰竭的处理及相关危险因素。方法回顾分析400例肝移植临床资料，观察术后急性肾功能衰竭病人的处理及预后。根据有无肾功能衰竭分组，对13项相关的危险因素进行单因素及多因素分析。结果肝移植术后早期急性肾功能衰竭的发生率为7．2％，均接受持续静脉静脉血液滤过治疗，1年生存率为44．4％。单因素分析中年龄、术前肝功能分级、术前肌酐、尿素氮、手术时间、术中输血量组间差异有统计学意义，多因素分析中只有术前肝功能分级是独立的危险因素。结论肝移植术后早期急性肾功能衰竭预后差，可能与多种诱发因素有关，术前肝功能不全是独立的危险因素。     

ABO血型不合的肝移植（附3例报道）

目的 探讨ABO血型不合的肝移植治疗急性肝功能衰竭的疗效.方法 回顾性分析我院急诊状态下开展的3例(布加综合征患者1例,肝癌患者1例,重症乙型肝炎患者1例)ABO血型不合的肝移植患者的临床资料,术后以四联免疫抑制剂抗排斥反应.结果 1例布加综合征患者术后相继出现肺部感染、脑桥髓鞘溶解症及急性排斥反应,经积极对症处理后缓解,现已存活14个月; 1例肝癌患者术后出现不可控制的感染,术后13 d因多脏器功能衰竭死亡; 1例重症乙型肝炎患者术后出现急性肾功能衰竭,给予持续肾脏替代疗法,肾功能恢复.结论 ABO血型不合的肝移植术后并发症多,通过加强围手术期管理和应用有效的免疫抑制方案,可提高ABO血型不合肝移植的疗效.在无合适供体的紧急情况下,ABO血型不合的肝移植可以作为急性肝功能衰竭患者的一个重要选择.     

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．     

肝移植术后早期肾功能衰竭的危险因素分析

目的 分析南京军区福州总医院肝移植术后早期.肾功能衰竭的危险因素,探讨其防治策略.方法 回顾分析该院72例肝移植病人的临床资料,包括年龄、性别、等待供肝时间、术前肝功能Child分级、血清肌酐水平、肾动脉阻力指数、血清总胆红素水平、PT、APTT,术中失血量、补液量、低血压总时间、腔静脉完全阻断时间、是否应用经典原位肝移植、是否使用人工肝等,并进行多因素分析,寻找术后早期肾功能衰竭的危险因素.结果 18例术后发生早期肾功能衰竭,发生率为25%;术前肌酐水平升高、肾动脉阻力指数增大、术中大量失血、术中低血压时间长、术中补液量大以及未使用术中人工肝等因素为早期肾功能衰竭的高危因素.结论 术前尽可能改善肾功能,术中尽量减少出血,维持血流动力学稳定,充分发挥术中人工肝持续血液滤过的作用,可有效降低肝移植术后早期肾功能衰竭的发生.     

Renal function in patients with orthotopic liver transplantation

Due to multiple reasons, acute renal failure (ARF) commonly develops in the early postoperative period of orthotopic liver transplantation (OLT) recipients. The records of OLT recipients between 1999 and 2004 were evaluated. Age, gender, primary disease, history of diabetes, immunosuppressive drugs, pre- and postoperative renal function tests, serum electrolytes, dialysis, liver functions tests, and renal function tests in follow-up period were noted. We followed 16 patients with OLT in our center. ARF developed in 8 patients. Dialysis was performed in only 2 patients, and other patients with ARF were managed with conservative measures. Hypertensive crisis and cerebrovascular stroke developed in 1 diabetic hypertensive patient.     

Renal Function in Patients with Orthotopic Liver Transplantation

Due to multiple reasons, acute renal failure (ARF) commonly develops in the early postoperative period of orthotopic liver transplantation (OLT) recipients. The records of OLT recipients between 1999 and 2004 were evaluated. Age, gender, primary disease, history of diabetes, immunosuppressive drugs, pre- and postoperative renal function tests, serum electrolytes, dialysis, liver functions tests, and renal function tests in follow-up period were noted. We followed 16 patients with OLT in our center. ARF developed in 8 patients. Dialysis was performed in only 2 patients, and other patients with ARF were managed with conservative measures. Hypertensive crisis and cerebrovascular stroke developed in 1 diabetic hypertensive patient.     

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.     

Acute renal failure in liver transplant recipients: role of pretransplantation renal function and 1-year follow-up

Chronic renal failure and acute renal failure (CRF and ARF) are common complications after orthotopic liver transplantation (OLT) that adversely affect patient survival. Many factors influence the development of ARF in the OLT setting. In a previous study we reported an association between ARF and the development of CRF at 1 month after OLT. The aims of our study were to evaluate the influence of ARF on short-, middle-, and long-term renal function after OLT and its influence on 1-year survival of patients and grafts.Fourty-four patients who underwent deceased donor OLT between August 2008 and August 2010 were evaluated pretransplantation, in the perioperative period, and at 1, 6, and 12 months posttransplantation. ARF was associated with CRF at 1 month post-OLT, whereas no association was observed at 6 and 12 months post-OLT. The development of CRF at 6 months post-OLT was associated with pre-OLT renal dysfunction and 1 month post-OLT CRF. Four patients died in the ARF group, whereas 3 patients died in the group without ARF. We confirmed ARF to be a predictive event for short-term renal dysfunction. The majority of patients recovered renal function after the first month. Although many pre-, peri-, and post-OLT factors may contribute to the development of posttransplantation CRF, pre-OLT CRF seemed to be the most important risk factor.     

肝移植术患者术后早期并发急性肾功能衰竭的危险因素

目的 分析肝移植术患者术后早期并发急性肾功能衰竭(ARF)的危险因素.方法 择期行肝移植术的终末期肝病患者60例,年龄28～64岁,术前血清肌酐和尿素未见异常.根据术后24h内是否发生ARF,分为2组:ABF组与非ARF组(NARF组).可能的危险因素进行组间比较后,将差异有统计学意义的因素进行logistic回归分析,筛选发生ARF的危险因素.结果 logistic回归分析结果显示,术前血β1-微球蛋白高于正常值、术中持续性低血压与术后早期并发ABF有关(P＜0.05).结论 肝移植术患者术前血β2-微球蛋白高于正常值和术中发生持续性低血压是术后早期并发ABF的危险因素.     

Acute renal failure after liver transplantation: incidence, etiology, therapy, and outcome

Acute renal failure (ARF) was a frequent complication after orthotopic liver transplantation (OLT) when ARF was defined by a calculated glomerular filtration rate decrease of >50% or by a doubled serum creatinine above 2.5 mg/dL within the first week after OLT. We analyzed 1352 liver transplant recipients in retrospective fashion with regard to the incidence, etiology, therapy, and outcome of ARF; 162 patients developed ARF within the first week after OLT (12%), among whom 157 patients (97%) were recompensated by postoperative day 28. Altogether 52 patients (32%) received an average of 6 hemodialysis treatments, excluding the 5 patients (3%) who developed end-stage renal failure. Risk factors for this complication included hepatorenal syndrome type II, a glomerular filtration rate of <50 mL/min, and a diagnosis of hepatitis C.     

Risk Factors of Acute Renal Failure After Orthotopic Liver Transplantation: Single-center Experience

Background

Acute renal failure (ARF) is one of the most significant complications of orthotopic liver transplantation (OLT), associated with increased mortality rate and the development of chronic renal dysfunction. The aim of the study was to determine the perioperative risk factors for ARF in patients without previous history of renal disease who are undergoing OLT.

Materials and methods

Forty-six patients who developed ARF after OLT performed in 1 transplant center were included in the study, and 52 consecutive patients without that complication served as a control group. Renal dysfunction was defined as a glomerular filtration rate <60 mL/min/1.73 m². The data concerning preoperative diseases, perioperative renal function, first-line immunosuppressive therapy, and blood transfusion requirement were retrospectively analyzed and compared among groups. Logistic regression modeling was used to determine risk factors for ARF.

Results

Patients who developed ARF were significantly older (mean age 53.3 vs 46.3 years, P = .057), had higher level of preoperative (0.79 vs 0.71 mg/dL, P = .0062) and intraoperative (0.85 vs 0.74 mg/dL, P = .0045) creatinine. The risk factors for ARF were intraoperative and 24-hour post-transplant creatinine level >0.9 mg/dL and high-dose tacrolimus-based immunosuppression. Transfusion of ≤6 units of red blood cells diminished the risk of ARF. Sex and preoperative diseases were not predictive to ARF in our regression models.

Conclusion

Careful operative technique with low blood loss and immunosuppressive therapy of low nephrotoxic potential should be recommended in older patients to diminish the risk of renal dysfunction after orthotopic liver transplantation. Patients with higher levels of perioperative creatinine should be considered to have first-line immunosuppression without calcineurin inhibitors or with low-dose immunosuppressants of known nephrotoxic potential.     

Renal function outcomes following liver transplantation and combined liver-kidney transplantation

Acute renal failure (ARF) is common immediately after orthotopic liver transplantation (OLT), whereas the incidences of chronic kidney disease (CKD) and end-stage renal disease increase with time. Introduction of the Model for End-stage Liver Disease (MELD) score-intended to prioritize patients with more-severe pretransplantation liver disease in general, and worse pretransplantation renal function in particular-for the allocation of liver grafts led to concerns about compromised patient and allograft survival and increased incidence of postoperative ARF and CKD. Nonetheless, it has been suggested that early OLT of candidates with baseline renal dysfunction improves post-transplantation renal outcomes. For OLT candidates with mild to moderate chronic renal impairment or recent-onset ARF, the decision of whether to perform OLT alone or combined liver-kidney transplantation (CLKT) can be challenging because no single factor has been shown to be predictive of the degree of renal function recovery or CKD progression following successful OLT. In this article, we provide an overview of the literature on renal function outcomes following OLT and CLKT, share our perspectives on the potential predictors of renal dysfunction or nonrecovery of renal function after OLT, and present United Network for Organ Sharing data on patient and allograft outcomes in CLKT recipients in the pre-MELD and post-MELD eras. Mechanisms that might underlie immunological protection of kidney grafts by liver allografts are also discussed.