大鼠脂肪变性供肝减体肝移植术后的肝再生

目的　探讨大鼠脂肪变性供肝减体肝移植术后的肝再生方式及相关机制。方法　采用 79%标准饲料、2 0 %猪油、1%胆固醇混合喂饲 ,同时以 5 0 %乙醇灌胃每日 1ml/10 0 g ,时间为 4周 ,诱导供肝脂肪变性形成 ,大鼠 60 %减体肝移植模型。观察和比较术后 1、3、7、14d时PCNA、Br dU免疫组织化学及新鲜分离的肝细胞的流式细胞术结果及肝再生率。结果　脂肪变性供肝减体肝移植术后 1、3、7d的肝再生率较正常明显减低 (P <0 .0 1) ;各时点的PCNA标记指数 (P <0 .0 1)和BrdU标记指数差异均有非常显著性 (P <0 .0 1) ;脂变供肝术后的肝细胞增殖指数 (PI)在 7d时最高 (2 6.3 1% ) ,而正常供肝在 3d时最高 (4 2 .0 1% )。结论　大鼠脂肪变性供肝减体肝移植术后肝再生的高峰时间滞后、周期延长。     

Liver replacement with reduced size donor organs

End stage liver disease in children can be treated with orthotopic liver transplantation (OLT). Nevertheless, the expansion of this therapy in Europe has been limited because of the shortage of appropriate size-matched donors. One possible technical solution is the OLT of a liver graft previously reduced in size by in situ resection preceding the harvesting procedure. To study the impact of this technique we examined two different operative procedures performed on Landrace pigs. Group 1 consisted of 20 standard donor/recipient weight matched OLT. In group 2, 15 OLT were performed using right lateral and medial lobes (55% of the original donor liver). The donor/recipient weight ratio in the group was 2:1. Cold ischemia times were 90 +/- 16 min for group 1 and 98 +/- 9 min for group 2. It is emphasized that in contrast to all the other reports using resected liver grafts for OLT, the donor resection in our study was always performed in situ under normothermic conditions, preceding the harvesting procedure. This was designed to reduce the cold ischemia time. No significant technical problems were encountered. The biochemical results of group 2 pigs compared to group 1 demonstrate an analogous, postoperative course. This might be explained by regenerative stimuli acting on the resected liver tissues and enhancing their metabolic function. These data support the conclusion that resected adult donor liver grafts may be used for pediatric transplant recipients.     

Liver transplantation using an organ donor with HELLP syndrome

BACKGROUND: The shortage of organs for liver transplantation has forced transplant centers to expand the donor pool by using donors traditionally labeled as marginal. One such example is liver transplantation using a donor with HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets), a disorder of late pregnancy that involves the liver as one of the target organs. METHODS: Two patients who died from complications of HELLP syndrome were evaluated for attempted multi-organ procurement. Donor characteristics, gross and microscopic liver findings, and procurement and transplant outcomes were reviewed. RESULTS: One of the liver allografts was successfully transplanted; the other was not procured because of poor macroscopic appearance. CONCLUSION: It is possible to successfully transplant the liver from a donor that succumbs to HELLP syndrome, provided there is adequate recovery of liver function before procurement.     

The use of contaminated donor organs in transplantation

Introduction. Organ transplantation has become an accepted means of treating end‐stage organ disease in recent years with acceptable patient and graft survival. Transplant recipients have an increased risk of infectious complications due to multiple factors including decreased host resistance from chronic end‐stage organ failure as well as from the immunosuppression required to prevent graft rejection.
Hypothesis. Therefore, the use of contaminated allografts could result in life‐threatening infections in organ recipients.
Method. In this study, transplant patients receiving organs from donors with positive blood or urine cultures, from 1993 to 1997, were retrospectively reviewed.
Results. There was a total of 599 organ donors in our state. Forty‐six (7.5%) had positive blood cultures and 25 (4.5%) had positive urine cultures. A total of 179 patients received organs from these contaminated donors, 36 of which were transplanted at our center. In this group, there were 16 kidney, 9 liver, and 11 heart transplants. Both donors and recipients received prophylactic broad‐spectrum antibiotics, which were adjusted based on culture and sensitivity results. The most common organisms isolated from the blood were staphylococci followed by streptococci and Gram‐negative organisms. Three of the 9 liver transplant patients in the series died with a mortality of 33%. Two of the 3 patients who died had sepsis but the responsible organisms were different from those recovered from the donor. The rest (66%) did well and have acceptable liver function. None of the 16 renal transplant recipients developed an infection and all survived. One patient developed acute irreversible rejection requiring transplant nephrectomy. There was one death in the heart transplant group resulting in a mortality of 9%. This death was not attributed to infectious processes. Three of 11 heart transplant patients grew organisms in the post‐operative period that were similar to those found in the corresponding donors. However, no patient suffered significant morbidity or mortality from these infections and all recovered. The recipients of contaminated organs had levels of organ function similar to those of randomly chosen recipients of non‐contaminated organs, and both groups had similar lengths of hospital stay.
Conclusion. Only 3 of 36 organ recipients had infections caused by organisms found in the contaminated donor organs for a rate of 8%. Contaminated donor organs seem to fare as well as non‐contaminated donor organs and there was no increase in morbidity or mortality. Contamination of organs should not be an absolute contraindication to the use of these organs in transplantation.     

Liver transplantation, including the concept of reduced-size liver transplants in children.

Since the establishment of a clinical program in liver transplantation in 1984, 162 liver transplants have been performed in 131 patients (78 adults, 53 children). The patient mortality rate while waiting for a suitable organ has been 8% for adults and only 4% for children (25-46% reported in the literature). The low pediatric mortality is a result of the use of reduced-size liver transplants. A total of 14 procedures have been performed in recipients whose clinical condition was deteriorating and for whom no full-size graft could be located. Of 14 children, 13 were less than 3 years of age. Patient survival is 50%, comparable to survival of high-risk recipients of full-size livers. Using reduced-size liver grafting in a transplant program can lower mortality for children awaiting a transplant by overcoming size disparity. Reduced-size liver grafting will allow more effective use of donor resources and provide a potential avenue of research for organ splitting and living related donation.     

Successful transplantation of organs retrieved from a donor with enterococcal endocarditis

We report on a patient with an extensive cerebral infarction secondary to enterococcal endocarditis that, in spite of adequate antibiotic treatment, evolved to brain death. The patient was evaluated as a potential organ donor; renal and liver function were normal and both liver and kidneys appeared normal on ultrasonographic examination. When negativity of serial blood and urine cultures was ascertained, liver and kidneys were retrieved for transplantation. The organs were transplanted into three recipients with good results after 14 months of follow-up. All of the recipients received antibiotic prophylaxis against Enterococcus faecalis. None of them has presented infectious complications to date. This case emphasizes that patients with enterococcal endocarditis may be potential organ donors provided both donor and recipients are adequately treated. This is especially important when organs are urgently needed. Received: 3 February 1998 Received after revision: 24 March 1998 Accepted: 15 April 1998     

Renal transplantation I. Use of donor organs with multiple vessels

The Cleveland Clinic experience in transplanting 46 kidneys with multiple vessels is reported. Suggested surgical techniques for the vascular anatomosis are recommended and long-term results of function and complications are reported. These kidneys can be safely and effectively used from both related living and cadaver donors.     

The use of expanded criteria donor organs for transplantation

Expanded criteria donors (ECD) of kidneys include all those aged ≥60 years and donors aged 50–59 years with at least 2 of the following 3 medical criteria: (1) cerebrovascular accident as the cause of death, (2) terminal serum creatinine concentration >1.5 mg/dL, and (3) history of systemic hypertension. ECD kidneys now account for 20% of all deceased donor kidneys in the United States, with the fraction being as high as 35% in some donation service areas. However, procured ECD kidneys continue to be discarded at a significantly higher rate (41%) compared with 8% for non-ECD kidneys. Patients who elect to be offered and receive ECD kidneys have survival benefits of decreased long-term mortality between 17% and 27% when compared to waiting longer and subsequently receiving an standard criteria donors organ, but only if the waiting time is more than 44 months. The experience with ECD kidneys in the United States suggests that organ donation and transplantation rates can be significantly improved through the systematic incorporation of ECD policies into organ procurement and transplantation schemes. More refined definition of ECD and rigorous assessment of the outcomes of ECD organ transplantation will further contribute to improving the use of all donated organs.     

Medium-term results of heart transplantation using older donor organs.

BACKGROUND: Donor heart shortage has necessitated the expansion of the donor pool by the use of older hearts. PATIENTS AND METHODS: In a 13-year period, 1,070 heart transplants were performed in 1,035 adults at the German Heart Institute Berlin. We divided the patients into 3 groups: Group I, donor age <35 years (n = 524); Group II, donor age 35 to 50 years (n = 379); Group III, donor age >50 years (n = 167). We analyzed post-operative mortality (up to 30 days), cumulative survival rates, cardiac dependent morbidity, and changes in the left/right ventricular ejection fraction as well as freedom from cytomegalovirus infection and freedom from acute rejection episodes grade >/= 2 (International Society for Heart and Lung Transplantation). We also calculated the rate of cardiac interventions per patient in the groups. RESULTS: Recipients in Group III were significantly older, compared with Groups I and II. The post-operative mortality was 16.8% in Group I, 29.8% in Group II, and 23.4% in Group III. The differences were significant (p = 0. 00001) between Group I and Group II. The long-term cumulative survival rates were significantly better in Group I when compared with Groups II and III (p < 0.00001, p = 0.014), but it did not differ between Groups II and III (p = 0.18). However, cardiac morbidity in Groups I and II was significantly lower when compared with Group III (p = 0.0009, p = 0.037). Mean left and right ventricular ejection fraction was >55% and did not significantly change in groups for up to 10 years. Freedom from cytomegalovirus infection was not significantly different between Groups II and III (p = 0.09). Significantly fewer percutaneous transluminal coronary angioplasties were performed in Group I, but comparable numbers were carried out in Groups II and III (p = 0.53). For retransplantation a similar situation occurred. CONCLUSION: We did not find significant differences in the mid-term follow-up between patients who received hearts from 35- to 50-year-old donors and from those who had received hearts from donors >50 years, despite increased cardiac morbidity in Group III. Close monitoring of the coronary situation after heart transplantation and expanded indications for revascularization in Group III makes heart transplantation with older hearts a suitable option to save the lives of patients in end-stage heart failure.     

Successful transplantation of donor organs from a hemlock poisoning victim

BACKGROUND: The poison hemlock plant (Conium maculatum) has been a known poison since early in human history, most notably as the agent used for the execution/suicide of Socrates in ancient Greece. No experience has been reported regarding the suitability of a hemlock victim's organs for transplantation. METHODS AND RESULTS: This report documents successful transplantation of the liver, kidney, and pancreas from a 14-year-old girl who died of anoxic encephalopathy from asphyxia after the accidental ingestion of fresh hemlock while on a nature hike. Predonation laboratory values were not remarkable, and liver and kidney biopsy results were normal. All organs in the three recipients had immediate function, and no recipient had any clinical evidence of transmitted toxin. All recipients are well, with functioning transplants at greater than 6 months after transplantation. CONCLUSIONS: Poison hemlock intoxication does not seem to be a contraindication to organ donation.     

Liver laceration associated with severe seizures after living donor liver transplantation.

Hemorrhagic complications commonly occur early after liver transplantation (LT), sometimes requiring emergent relaparotomy. However, active bleeding from the liver graft itself is a rare but life-threatening complication after living donor liver transplantation (LDLT). We report an unusual case of liver laceration with massive bleeding, associated with severe epileptic seizures as a result of tacrolimus-induced leukoencephalopathy, after LDLT. The patient was successfully rescued by conventional surgical management without a second transplantation. In conclusion, to our knowledge this is the first reported case of graft rupture due to immunosuppression-associated leukoencephalopathy after LT.     

Liver transplantation in children using organs from young paediatric donors

Nowadays, most paediatric liver transplant recipients receive a split or other technical variant graft from adult deceased or live donors, because of a lack of available age‐ and size matched paediatric donors. Few data are available, especially for liver grafts obtained from very young children (<6 years). We analysed all paediatric liver transplantations between 1989 and 2009. Recipients were divided into five groups (1–5) depending on donor age (<1, ≥1 to <6, ≥6 to <16, ≥16 to <45, ≥45 years). Overall, 413 paediatric liver transplantations from deceased donors were performed; 1‐ and 5‐year graft survival rates were 75%, 80%, 78%, 81%, 74% and 75%, 64%, 70%, 67%, 46%, and 1‐ and 5‐year patient survival rates were 88%, 91%, 90%, 89%, 78% and 88%, 84%, 84%, 83%, 63% for groups 1–5, respectively, without significant difference. Eight children received organs from donors younger than 1 year and 45 children received organs from donors between 1 and 6 years of age. Overall, vascular complications occurred in 13.2% of patients receiving organs from donors younger than 6 years. Analysis of our data revealed that the usage of liver grafts from donors younger than 6 years is a safe procedure. The outcome was comparable with grafts from older donors with excellent graft and patient survival, even for donors younger than 1 year.     

Liver transplantation using organs from donors older than 60 years

At present, it is frequently accepted to expand the organ pool for liver transplantation (LTx) by including livers from critical donors. From 1990 to June 2002 a total of 1,208 LTx were performed. Of those, 67 livers from donors older than 60 years were transplanted to 66 patients, including re-LTx in eight patients. Fourteen patients had malignant diseases (21%). Ten patients had a high urgency status (15%). Median donor age was 65 years (range 61–80 years). Primary graft function was observed in 84%. Patient survival rate at 1 and 5 years was 79% and 62%, and graft survival was 68% and 53%, respectively. No difference was observed in LTx with livers from donors younger than 60 years. Fifteen graft losses occurred during the study. Surgical complications were observed in 23 patients (34%). The outcome of LTx with livers from donors older than 60 years is satisfactory and is comparable to results of LTx with livers from donors younger than 60 years. The frequency of vascular complications and cholestasis syndrome is not increased.