Glomerular abnormalities in children undergoing orthotopic liver transplantation

A prospective study of renal function was undertaken on an unselected group of 8 children with chronic progressive liver disease on whom a renal biopsy was performed subsequently at the time of orthotopic liver transplantation. Two patients had abnormal urinalyses and 2 elevated urinary albumin/creatinine ratios. The remainder had no clinical evidence of renal dysfunction. All had normal serum creatinine concentrations. Glomerular abnormalities were present in all renal biopsies and were of two types: hepatic glomerulosclerosis (n=5) and minor glomerular abnormalities (n=3). IgM immunofluorescence was present in all biopsies and IgA in 6. Elevated serum immunoglobulin levels were observed in all patients, with IgM elevation in 6, IgA in 4 and IgG in 6. C3 and/or C4 were reduced in 5 patients and increased circulating immune complexes containing IgM were noted in 4. The clinical significance of these cirrhosis-associated glomerular abnormalities can only be established by long-term follow-up studies after orthotopic liver transplantation.     

Extrahepatic metabolism and renal effects of sevoflurane in a case of liver transplantation

In a case of liver transplantation, sevoflurane metabolism was studied to investigate if sevoflurane has an extrahepatic metabolism or possible nephrotoxicity in the presence of chronic liver disease. Plasma blood urea nitrogen (BUN) and creatinine and urine levels of N-acetyl glycosaminidase (NAG) and beta2 microglobulin were assessed intraoperatively and for 11 days postoperatively. We observed a close relation between urine NAG excretion and urine inorganic fluoride levels in the intraoperative period and early postoperative days. The NAG levels were greater than normal despite the peak serum inorganic fluoride concentration of 18.94 micromol/L. No impairment was observed in serum BUN or creatinine levels in these periods.     

原位肝移植患者术中氧代谢的变化

目的观察非静脉-静脉转流原位肝移植术患者术中全身氧代谢变化。方法23例接受非静脉-静脉转流原位肝移植的终末期肝病患者,全麻诱导用咪唑安定、依托咪酯、芬太尼和阿曲库铵,以异氟醚、丙泊酚、阿曲库铵、间断静注芬太尼维持麻醉,通过左侧桡动脉置动脉导管和右颈内静脉置Swan-Ganz导管。分别在麻醉后手术开始前(T1)、无肝期前10min(T2)、无肝期30min(T3)、新肝期30min(T4)及术毕(T5)采动脉血和混合静脉血,监测和计算以上各时点的SaO2、PaO2、SV-O2、心脏指数(CI)、氧供(DO2)、氧耗(VO2)和氧摄取率(ERO2)。结果与T1时相比,T2时S-VO2增加(P<0.05),DO2和VO2无明显变化,而ERO2下降。在T3时DO2和VO2下降明显(P<0.01),而ERO2则提高(P<0.05)。在T4时DO2、VO2和ERO2恢复至T1水平。至术毕时与无肝期无明显变化。结论非静脉-静脉转流下经典原位肝移植术患者术中氧代谢存在严重异常,以无肝期最为严重,氧供和氧耗明显下降,氧摄取率增加。     

原位肝移植术后感染分析

目的 探讨原位肝移植术后感染的特点及其易感因素，提高肝移植术后感染的诊治水平。方法 对250例原位肝移植术后感染患者的资料进行了回顾性分析，以术前、术中及术后主要的临床和实验室指标作为观察对象，分析感染组和非感染组间的差别。结果 250例原位肝移植患者术后发生感染的共163例，感染率为65.2%。最常见感染部位依次为血液、泌尿道和呼吸道。单个部位感染91例，两个部位感染45例，多个部位感染共27例。最常见为细菌感染，约89.6% （146/163），其中单一细菌感染62例，两种细菌感染27例，多种细菌同时感染19例。其次为真菌感染，占27.0%（44/163），44例中38例患者同时伴有细菌感染。病毒感染6.7%（11/163）。大部分感染均发生在围手术期内。Logistic回归分析表明肝移植患者年龄大于60岁、术前肝功能Child-Pugh C级、手术时间、术中输血总最〉1000ml、术后胸水、重症监护室（ICU）住院天数是术后感染的独立危险因素。结论 原位肝移植术后感染率高，多部位、多种病原菌的混合感染以及多重耐药菌日益增多。应重视对感染易感因素的控制，降低移植术后感染的发生率。     

Influence of N-acetylcysteine on hepatic amino acid metabolism in patients undergoing orthotopic liver transplantation

Experimental treatment with the antioxidant and glutathione precursor N-acetylcysteine (NAC) has been performed in orthotopic liver transplantation (OLT) to reduce reperfusion injury. To investigate the effect of NAC on the hepatic and intestinal amino acid metabolism, intraoperative amino acid exchange rates were studied in liver transplant recipients with high dose NAC treatment (n = 10) and in control patients (n = 9). Treatment with NAC was found to cause a loss of amino acids and increased urea nitrogen release from the liver graft. The net balance of most amino acids was shifted to increased hepatic release or decreased hepatic uptake. The initial cumulative splanchnic release of all proteinogenic amino acids in the NAC treated group was significantly higher than in the control group. These findings are tentatively explained by an increased net protein catabolism in the liver. The increased hepatic urea and glutamine production rate of the NAC treated patients is expected to increase the energy and oxygen demand of the liver in this critical situation. Thus, NAC may have caused marked metabolic disturbances in the freshly implanted graft. The dosage of NAC should therefore be modified to avoid these disadvantages. Received: 19 April 2000 Revised: 27 February 2001 Accepted: 8 June 2001     

原位肝移植术临床麻醉管理的探讨

目的 探讨成年人原位肝移植术期的变化及麻醉处理。方法 采用全身麻醉或全身麻醉或全身麻醉复合硬外麻醉;无肝期采用体外静脉转流;术中监测动力学、呼吸功能、血气、生化、凝血功能、体温、血糖、尿量及出血量。根据原位肝移植术无肝前期、无肝期、新肝期的特点,给予相应的麻醉处理。结果 无肝期均外静脉转流技术,可以使术中血液动力学埸于稳定。无肝期初期及新肝期理。结果 无肝期均采用体外静脉转流技术,可以使术中血液动     

原位肝移植术的麻醉管理

目的探讨成年原位肝移植术病人围手术期血流动力学、内环境变化和麻醉管理方法。方法52例晚期肝病行背驮式原位肝移植术病人，采用静吸复合全身麻醉。术中监测血流动力学、血气、生化指标、凝血功能、体温、尿量及出血量等。根据成人原位肝移植术无肝前期、无肝期、新肝期的特点及术中具体情况，给予相应的处理。结果52例行肝移植术病人无术中死亡。围手术期血液动力学基本平稳。pH值和BE等代谢性指标变化较大；所有病人手术期间血游离Ca^2 均偏低。术中体温变化不大。结论肝移植手术期间血流动力学、凝血因子、电解质和酸碱平衡等变化复杂，应加强麻醉管理和监测，并积极实施血液保护措施。     

血液净化在肝移植围手术期的应用

目的探讨血液净化在肝移植围手术期患者中的应用价值。方法回顾性分析42例肝移植围手术期患者进行血液净化包括血浆置换(plasma exchange,PE)和持续肾脏替代治疗(continuous renal replacement therapy,CRRT)的结果。结果29例肝移植患者移植前后行PE治疗(其中5例联合血液灌流),25例患者顺利过渡到肝移植,移植后的25例患者1年存活率为68%。PE治疗前后CD3~+分别为70．5%±9．3%及53．9%±6．4%,CD8~+(29．7%±8．1%,18．9%±7．3%)和CD25~+(12．3%±6．4%,9．6%±5．9%)下降,CD20~+(10．9%±6．9%,22．0%±8．6%)上升,IgG [(16．9±2．4)g/L,(12．2±1．5)g/L]和IgA[(6．4±1．5)g/L,(3．6±0．8)g/L)]下降,补体C3 [(0．35±0．17)g/L,(0．60±0．19)g/L)]和CH50[(9．6±3．0)×10~4U/L,(15．7±1．3)×10~4U/L]增高。19例患者移植前后进行CRRT治疗,9例肾功能恢复,移植后存活7例。移植后需要CRRT支持的17例患者1年存活率为41．2%。7例患者既行PE又行CRRT治疗,移植后4例存活。治疗期间无严重并发症发生。结论血浆置换可以改善患者凝血功能及一般情况;肝移植加人工肝支持系统是治疗肝衰竭的有效方法;以CRRT为基础的综合疗法能有效治疗肝移植术后急性肾衰竭的患者。     

去甲肾上腺素对肝移植术中患者血流动力学的影响

目的 观察单用去甲肾上腺素对肝移植术中患者血流动力学的影响.方法 择期行原位肝移植术的晚期肝硬化患者40例.随机均分为去甲肾上腺素组(N组)和多巴胺组(D组).分别于切皮前(T0)、切皮后1 h(T1)、无肝期30 min(T2)、新肝期1 h(T3)及新肝期4 h(T4)监测血流动力学指标.结果 与T0时相比,两组HR在T1～T4时均增快(P<0.05);N组MAP在T2时明显高于D组(P<0.05),而D组HR在T2时又明显高于N组(P<0.05);与T0时相比,两组CVP、平均肺动脉压(MPAP)、心输出量(CO)、心指数(CI)T2时均下降(P<0.05);与T2时相比,两组以上指标在T3时均上升(P<0.05).但组间差异无统计学意义;与T0时相比,两组体循环血管阻力(SVR)及其指数(SVRI)、肺循环血管阻力(PVR)及其指数(PVRI)在T2时均卜升(P<0.05);与T2时相比,两组以上指标在T3时均下降(P<0.05),但组间差异无统计学意义.结论 在晚期肝硬化患者行肝移植手术中,单用去甲肾上腺素和多巴胺均可有效维持血流动力学稳定,且去甲肾上腺素对HR影响小,升高BP效果更明显.     

Predictors of clinical outcome in children undergoing orthotopic liver transplantation for acute and chronic liver disease.

The current United Network for Organ Sharing (UNOS) policy is to allocate liver grafts to pediatric patients with chronic liver disease based on the pediatric end-stage liver disease (PELD) scoring system, while children with fulminant hepatic failure may be urgently listed as Status 1a. The objective of this study was to identify pre-transplant variables that influence patient and graft survival in those children undergoing LTx (liver transplantion) for FHF (fulminant hepatic failure) compared to those patients transplanted for extrahepatic biliary atresia (EHBA), a chronic form of liver disease. The UNOS Liver Transplant Registry was examined for pediatric liver transplants performed for FHF and EHBA from 1987 to 2002. Variables that influenced patient and graft survival were assessed using univariate and multivariate analysis. Kaplan-Meier analysis of FHF and EHBA groups revealed that 5 year patient and graft survival were both significantly worse (P < 0.0001) in those patients who underwent transplantation for FHF. Multivariate analysis of 29 variables subsequently revealed distinct sets of factors that influenced patient and graft survival for both FHF and EHBA. These results confirm that separate prioritizing systems for LTx are needed for children with chronic liver disease and FHF; additionally, our findings illustrate that there are unique sets of variables which predict survival following LTx for these two groups.     

Human natriuretic factor in cirrhotic patients undergoing orthotopic liver transplantation

We measured the plasma levels of atrial natriuretic factor (ANF) during orthotopic liver transplantation (OLT) in eight adult patients with cirrhosis and ascites. The aim of this study was to determine whether significant differences in ANF concentration may be detected during the individual phases of OLT and to correlate these changes with hemodynamics. In each patient a hemodynamic assessment was achieved using a Swan-Ganz fiber optic catheter for continuous monitoring of cardiac output (CO), systemic vascular resistance index (SVRI), right filling pressure as assessed by central venous pressure (CVP), and left filling pressure by means of pulmonary arterial wedge pressure (PAWP). During reperfusion a clear-cut increase in ANF values was observed (P<0.05). Concurrently, an increase in CVP (P<0.05) and a decrease in SVRI were observed without any significant increase in diuresis. These data suggest that ANF might play a role in the development of the reperfusion syndrome.     

Analysis of growth in children after orthotopic liver transplantation

Growth after pediatric liver transplantation is an important factor in determining the quality of life. We collected data on height, skeletal age, and liver function of 45 consecutive pediatric transplant recipients and assessed the influence of primary diagnosis, liver function, and immunosuppressive regimen on their growth. Height and skeletal age were plotted as median standard deviation scores versus years post-transplantation. Growth, in terms of both height and skeletal age, were continuous without catch-up growth. Primary diagnosis was found to have no influence on height and poor liver function had a negative effect on both height and skeletal growth. A higher alternate day prednisolone maintenance dose also had a negative effect on skeletal growth. Thus, it can be concluded that a pretransplant lack of growth will not be restored and is an indication for early transplantation in endstage liver disease, especially in younger children.     

Intensive care course after orthotopic liver transplantation in children

Eight children 1 to 13 years old, were submitted to OLT. Six patients had normal liver function and complete rehabilitation 4 to 17 months after OLT. Two patients died during their ICU course respectively on day 15 and 34 after operation. The ICU management of the surviving patients is compared to the two fatal cases. At the time of admission in the ICU, there was no difference between the two groups, except for age. All patients were physiologically stable and needed essentially continuous monitoring and nursing care. All were rapidly weaned off artificial ventilation. During the first week after operation, surviving patients demonstrate improvement of liver function test, absence of infection, normal renal function and short ICU stay. They all suffered from systemic hypertension easily controlled by drugs. The two fatal cases were less than 15 months old and did not show improvement of their liver function. They suffered from severe infection, renal failure and protracted systemic hypertension and needed prolonged invasive monitoring and therapy.     

Intraoperative blood transfusions in highly alloimmunized patients undergoing orthotopic liver transplantation

Intraoperative blood requirements were analyzed in patients undergoing primary orthotopic liver transplantation and divided into two groups on the basis of panel reactive antibody of pretransplant serum measured by lymphocytotoxicity testing. One group of highly sensitized patients (n = 25) had PRA values of over 70% and the second group of patients (n = 26) had 0% PRA values and were considered nonsensitized. During the transplant procedure, the 70% PRA group received considerably greater quantities of blood products than the 0% PRA group--namely, red blood cells: 21.1 +/- 3.7 vs. 9.8 +/- 0.8 units (P = 0.002), and platelets: 17.7 +/- 3.2 vs. 7.5 +/- 1.5 units (P = 0.003). Similar differences were observed for fresh frozen plasma and cryoprecipitate. Despite the larger infusion of platelets, the blood platelet counts in the 70% PRA group were lower postoperatively than preoperatively. Twenty patients in the 70% PRA group received platelet transfusions, and their mean platelet count dropped from 95,050 +/- 11,537 preoperatively to 67,750 +/- 8,228 postoperatively (P = 0.028). In contrast, nearly identical preoperative (84,058 +/- 17,297) and postoperative (85,647 +/- 12,445) platelet counts were observed in the 17 0% PRA patients who were transfused intraoperatively with platelets. Prothrombin time, activated partial thromboplastin time, and fibrinogen levels showed no significant differences between both groups. These data demonstrate that lymphocytotoxic antibody screening of liver transplant candidates is useful in identifying patients with increased risk of bleeding problems and who will require large quantities of blood during the transplant operation.     

丙酮酸乙酯预先给药对原位肝移植术大鼠肝损伤的影响

目的 评价丙酮酸乙酯预先给药对原位肝移植术大鼠肝损伤的影响.方法 成年健康雄性SD大鼠40只,体重220～ 250 g,作为肝移植术的供体和受体.采用随机数字表法,将受体大鼠随机分为3组(n=8):假手术组(S组)、肝移植组(LT组)和丙酮酸乙酯组(EP组).S组仅行单纯开关腹手术,LT组和EP组分别采用二袖套法建立大鼠原位肝移植模型,EP组于切皮前1h时尾静脉注射丙酮酸乙酯40 mg/kg.于新肝期2h时采集静脉血样,检测血清ALT和AST的活性;取肝中叶组织检测MDA含量和SOD活性.结果 与S组比较,LT组和EP组血清ALT、AST的活性和肝组织MDA含量升高,SOD活性降低(P＜0.05或0.01);与LT组比较,EP组血清ALT、AST的活性和肝组织MDA含量降低,SOD活性升高(P＜0.05或0.01).结论 丙酮酸乙酯预先给药可减轻原位肝移植术大鼠肝损伤.     

去甲肾上腺素对原位肝移植术患者肾功能的影响

目的 探讨去甲肾上腺素对原位肝移植术患者肾功能的影响.方法 择期行原位肝移植术的晚期肝硬化患者40例,年龄40～60岁,体重53～78 kg,ASAⅢ级或Ⅳ级,随机分为2组(n=20):去甲肾上腺素组(N组)术中静脉输注去甲肾上腺素,初始输注速率为0.01～0.02 μg·kg-1 min-1;多巴胺组(D组)术中静脉输注多巴胺,初始输注速率为1～2 μg·kg-1·min-1.调整无肝前期、无肝期和新肝期去甲肾上腺素输注速率分别为0.01～0.05、0.03～0.25和0.02～0.40 μg·kg-1·min-1;多巴胺输注速率分别为1～5、3～30和1～10 μg·kg-1·min-1,以维持无肝期平均动脉压(MAP)60～80 mm Hg,其他时期MAP 60～100mm Hg.分别于切皮前、切皮后1 h、无肝期30min、新肝期1 h及4 h时记录、心输出量、体循环血管阻力,计算心指数及体循环血管阻力指数,于上述各时点抽取中心静脉血,并留取尿液,测定各项肾功能指标,术后1周内测定肾功能指标.结果 两组间各时点血液动力学指标比较差异无统计学意义(P＞0.05),血清胱抑素C(Cys C)、血清β2-微球蛋白(β2-MG)、血清肌酐(Cr)及血清肌酐清除率(CCr)均在正常范围内,组间及组内比较差异均无统计学意义(P＞0.05).D组于切皮后1 h时尿β2-MG高于N组(P＜0.05).两组无肝期尿量、术中总尿量、术中呋塞米用量及术后24 h尿量比较差异无统计学意义(P＞0.05).两组术后1周内各时点血清β2-MG、Cr及CCr均在正常范围内.结论 原位肝移植术中静脉输注去甲肾上腺素对患者肾功能无不利影响.     

A new method of segmental orthotopic liver transplantation in children

Orthotopic liver transplantation requires matching of the donor and recipient for size. The rarity of suitable pediatric and infant donors in many countries has resulted in the acceptance of the principle of a reduced-sized adult liver graft for children. A new method of segmental orthotopic liver transplant is described. This method involves resecting the recipient liver off the inferior vena cava, which is left in situ, and the donor hepatic vein is anastomosed end to side to the inferior vena cava. The technique allows orthotopic liver transplantation with widely mismatched sizes from adults to infants.