Embryonal rhabdomyosarcoma of the orbit in a liver transplant recipient

Although an increased incidence of de novo malignancies is reported in transplant recipients, rhabdomyosarcoma, an aggressive mesenchymal tumor typical of childhood, is not considered a neoplasm commonly related to immunosuppression. A 21-year-old woman presented with unilateral diplopia and proptosis 16 months after liver transplantation for fulminant hepatic failure. A tumoral mass originating from the medial rectus muscle was partially removed and diagnosed as being an embryonal rhabdomyosarcoma. Since the patient refused complete orbital excision, one course of radiotherapy and six courses of chemotherapy were administered, while immunosuppression was re-modulated, without interruption of the administration of cyclosporine. Complete control of tumor growth was achieved, while no alterations of graft function were observed throughout the treatment period.     

活体肝部分移植术的受体手术技术

１９９７年６月３０日我们成功地进行了一例肝部分移植术，至今已生存５月余，活体肝部分移植术无论是病肝切除，还是新肝植入有其特殊性，根据在国外学习的经验和本次手术的体会，从手术麻醉、切口选择、肝脏游离和解剖、病肝切除、肝血管的修整、新肝植入和创面处理等方面对受体手术的肢巧作一介绍。     

肝移植术后激素七天撤离方案的临床疗效评价

目的 评价肝移植术后激素7 d撤离方案的临床有效性及安全性.方法 将2005年10月至2007年10月收治的76例供受者血型相同的首次肝移植患者动态随机法分为两组:术后7 d激素撤离组(7 d组,40例)和术后3个月激素撤离组(3个月组,36例),两组均采用以他克莫司(FK506)为基础的免疫抑制方案.7 d组激素用法:术中静脉滴注1000 mg甲泼尼龙,术后按500、240、200、160、80、40和20 mg依次递减,7 d后停用;3个月组激素用法:按7 d组方案静脉滴注甲泼尼龙7 d后,改用甲泼尼龙口服,每隔3 d依次按48、40、32、24、16、8和4 mg递减18 d,然后4 mg口服至术后3个月.随访6个月并评价术后急性排斥反应发生率和不良反应发生率.结果 共有69例完成全部随访,7例患者因死亡和严重细菌感染等原因于相应时间终止实验.两组患者在术后急性排斥反应、高脂血症、高血压发生率方面的差异均无统计学意义(P>0.05);7 d组术后糖尿病的发生率(17.5%比38.9%,X2=4.335,P=0.047)明显低于3个月组.结论 供受者血型相同的肝移植采用以FK506为基础的免疫抑制方案时,术后7 d激素撤离是安全有效的,不增加急性排斥反应发生率,并可以明显降低术后糖尿病发生率.     

Extrahepatic biliary stricture associated with cytomegalovirus in a liver transplant recipient

We describe a patient who developed a stricture in the distal common bile duct 6 weeks after orthotopic liver transplantation. Histopathologic examination of the bile duct epithelium in the region of the stricture showed characteristic cytomegalovirus (CMV) inclusions. CMV was also identified in pulmonary alveoli and in the duodenum. Although CMV has been demonstrated in the biliary epithelium of AIDS patients with extrahepatic biliary strictures and biliary obstruction, this entity has not, to our knowledge, been described in liver transplant recipients. This report confirms that CMV infection should be included as a probable cause of extrahepatic biliary strictures and bile duct obstruction in liver transplant patients.     

肝移植后并发他克莫司不良反应者的西罗莫司单药转换治疗14例

目的 总结出现钙调磷酸酶抑制剂(CNI)相关并发症的患者采用西罗莫司(SRL)单药转换治疗的体会.方法 肝移植患者14例,其中因CNI类药物致肾功能受损而行转换治疗者13例,因移植后血糖升高而行转换治疗者1例.转换治疗前,患者采用他克莫司(Tac)和糖皮质激素预防排斥反应,部分患者还加用霉酚酸酯.进行转换治疗后,初次给予SRL 4 mg/d;1周内给予SRL 1～2 mg/d,同时Tac的用量减至原来的一半;治疗1周后,根据血SRL浓度调整其剂量,维持血SRL浓度谷值为5～10μg/L,于转换治疗后1～2周完全撤除Tac.观察患者转换治疗后并发症的改善情况,肾功能、肝功能和急性排斥反应的发生情况及药物不良反应等.结果 转换治疗前,13例肾功能受损者的血肌酐为(158.3±41.6)μmol/L,随访结束时降低到(103.7±21.2)μmol/L;另1例血糖升高者在转换治疗后血糖得到有效控制,胰岛素用量由转换前的80 IU/L减少至24 IU/L.转换治疗后6个月内,14例中有2例(14.3%)发生急性排斥反应,治疗后均逆转.随访过程中,4例出现血脂升高,4例出现贫血或血小板减少,5例出现溃疡型口疮,但无患者因SRL不良反应而终止转换治疗.结论 肝移植术后出现CNI相关并发症的患者可以采用SRL单药转换治疗.     

他克莫司缓释胶囊对肝移植术后稳定期受者安全性和临床疗效评估

目的通过他克莫司缓释胶囊（MR4）的Ⅲ期临床试验（MR4LTxCN02）评价MR4在肝移植术后稳定期受者中的安全性和临床疗效。方法受试者随机分配入MR4或他克莫司（FK506）组,MR4组药物剂量按1：1进行药物转换,每日口服1次;FK506组维持每12h服药1次至试验结束。在为期3个月的临床试验阶段,随访了受试者生命体征、不良事件、血常规、尿常规、肝功能、血糖、血脂及FK506的谷值浓度。随访结果采用SAS8．0统计软件进行了Fisher精确卡方检验及t检验分析。结果MR4组按1：1药物转换后与FK506组具有同等的安全性和临床疗效。与FK506组比较,MR4组具有感冒、上呼吸道感染症状减少倾向,没有增加不良事件或不良反应的发生率。转换药物后的剂量和血药浓度与换药前未发生显著变化;药代动力学检测结果表明,MR4具备缓释剂型的药代动力学特征,并与FK506具有良好的生物等效性。结论MR4与FK506具有同等的安全性和临床疗效,同时简化了服药次数,在提高受者长期依从性以及术后生活质量方面具有较大的优势。     

Intercostal hernia and spontaneous pneumothorax in a liver transplant recipient: a case report

Intercostal hernia can occur after blunt trauma and can also complicate thoracotomy. This report describes a 13-year-old liver transplant recipient with chronic asymptomatic intercostal hernia at site of thoracotomy. This hernia became manifest upon development of spontaneous pneumothorax. She presented with pleuritic pain and radiographic evidence of spontaneous pneumothorax. Her history included liver transplantation at age 19 months for tyrosinemia, posttransplant lymphoproliferative disorder at age 7 years with thoracotomy for lung biopsy, and prolonged corticosteroid administration. Examination and computed tomography revealed an intercostal hernia. She underwent repair of hernia, stapled resection of apical blebs, and pleurodesis. Reconstruction of chest wall involved rib fracture and intercostal approximation with nonabsorbable sutures covered by serratus muscle advancement. She is symptom free with intact repair 2 years and 9 months after surgery and is able to participate in vigorous physical activity. This is the first report of an intercostal hernia detected upon development of spontaneous pneumothorax. The hernia occurred at the site of a prior thoracotomy, possibly because of impaired healing from corticosteroid administration. This case suggests that nonabsorbable sutures should be used for intercostal approximation after thoracotomy in patients with impaired wound healing.     

Dysarthria and cerebellar ataxia: late occurrence of severe neurotoxicity in a liver transplant recipient

Neurological complications of cyclosporin (CyA) therapy are frequent, usually occurring within the 1st month after transplantation. Though leukoencephalopathy is one of them, it is rarely documented. Here we report the case of an anti-HCV-positive patient with cirrhosis who underwent liver transplantation and developed cyclosporin-induced leukoencephalopathy. The presenting symptoms were dysarthria, difficulty walking, and dysphagia. They were first noted 6 months after transplantation in association with an episode of recurrent HCV acute hepatitis. White matter abnormalities were evident on computed tomography (CT) scanning and magnetic resonance (MR) imaging. This condition improved to some degree after cyclosporin withdrawal. To our knowledge this is the second reported case of CyA neurotoxicity occurring late after liver transplantation. Moreover, the association with acute hepatitis suggests the possibility of graft dysfunction as a contributing and triggering factor.     

Clostridial infection in a liver transplant recipient

Clostridium perfringens infection in a liver transplant recipient is a rare complication. We report a case of a liver allograft gas gangrene. The case illustrates the fulminant and rapidly devastating course of this complication.     

Case report of unchanged tacrolimus clearance in a hypoxemic pediatric liver transplant recipient with hepatopulmonary syndrome

Reductions in hepatic oxygen supply may reduce the oxidative metabolism of drugs, including tacrolimus. We encountered a patient (2.3-year-old girl) with hypoxemia [arterial oxygen tension (PaO₂) 40.9 mmHg in room air] due to hepatopulmonary syndrome who had undergone living related liver transplantation. After transplantation, tacrolimus was initially administered by continuous intravenous infusion, and her PaO₂ was maintained at more than 50 mmHg [72.8±10.4 (SD) mmHg] by oxygen supplementation. Apparent clearance of tacrolimus (calculated as: the infusion rate of tacrolimus/blood concentration) in the patient (0.075 l/h per kg) was comparable to those of non-hypoxemic control pediatric cases (0.092±0.014 l/h per kg, n=7, mean age 2.2 years, PaO₂ 149.2±41.5 mmHg), except for the acute decline in the early period after transplantation. These findings suggest that the reduction in tacrolimus clearance is negligible when arterial oxygen tension is maintained at more than 50 mmHg, even in patients with hypoxemia.     

Preoperative recipient data and immunosuppression levels are predictive of early patient survival after liver transplantation

Abstract The role of donor, preoperative, intraoperative, and postoperative factors in predicting patient survival after liver transplantation was evaluated by the Bio Medicus data package on a database containing 162 variables filled with records from 100 consecutive first-liver transplant cases. Donor data did not predict outcome. Recipient preoperative data (Child status, HCV status) were predictive using life table and Cox regression methods. Recipient intraoperative data (by-pass time, warm ischemia time, delay in arterial revascularization, and packed red blood cell requirements) were predictive of outcome using life table analysis. Recipient postoperative data (rejection, sepsis, primary dysfunction, and hepatic artery thrombosis) were predictive of outcome.     

扫描式葡萄糖监测系统在肝移植术后早期受者中的应用研究

目的探讨扫描式葡萄糖监测(FGM)系统在肝移植术后早期受者中的应用。 方法选取2019年4月至8月在中山大学附属第一医院器官移植中心行同种异体肝移植术的28例受者，应用FGM系统(美国雅培公司)连续监测组织间液葡萄糖浓度。同时采集受者清晨空腹血液标本，使用全自动生化分析仪检测静脉血糖值作为参考，评估FGM血糖值临床应用的精准性。使用R语言3.6.1软件进行克拉克误差网格分析。采用配对t检验或秩和检验比较术后第1周与第2周FGM结果，采用Pearson相关分析比较FGM血糖值与静脉血糖值的相关性。计算FGM血糖值与静脉血糖值配对数据的平均相对误差绝对值(MARD)和决定系数r²，比较两种血糖检测方法的一致性。P<0.05为差异有统计学意义。 结果28例受者平均佩戴FGM系统时间为(12.5±2.4)d(7～14 d)，佩戴期间均未出现过敏、瘙痒、皮肤红斑、青紫和疼痛等不良反应，均未出现传感器脱落。FGM系统佩戴期间，28例受者预估糖化血红蛋白为(6.7±1.7)%，FGM血糖值为(8±3)mmol/L，目标范围内时间为(72±34)%，低于和高于目标范围时间中位数分别为1%和8%。3例受者FGM血糖值全程在目标范围内，23例出现过高于目标范围，14例出现过低于目标范围。肝移植术后第2周FGM血糖值低于术后第1周，分别为(8±3)、(9±4)mmol/L，差异有统计学意义(t＝2.4，P<0.05)；术后第2周低于目标范围时间中位数(1%)高于术后第1周(0%)，差异有统计学意义(z＝-2.5，P<0.05)。FGM系统佩戴期间共采集244对空腹FGM血糖值与静脉血糖值，平均血糖值分别为(7±4)、(8±4)mmol/L，二者呈高度正相关(r＝0.976，P<0.05)。以全自动生化分析仪检测的静脉血糖值作为参考，克拉克误差网格分析结果示：FGM血糖值有93%(227/244)落在A区，有7%(17/244)落在B区。MARD＝9.8%，r²＝0.95。 结论FGM系统在肝移植术后早期受者中的临床应用是可行的，与常规间断末梢血糖监测方法相比，可监测到更多血糖异常事件及其持续时间，并及时采取有效治疗措施，控制血糖水平在最佳范围。     

Portal vein thrombosis after intraportal hepatocytes transplantation in a liver transplant recipient

Hepatocytes transplantation is viewed as a possible alternative or as a bridge therapy to liver transplantation for patients affected by acute or chronic liver disorders. Very few data regarding complications of hepatocytes transplantation is available from the literature. Herein we report for the first time a case of portal vein thrombosis after intraportal hepatocytes transplantation in a liver transplant recipient. A patient affected by acute graft dysfunction, not eligible for retransplantation, underwent intraportal infusion of 2 billion viable cryopreserved ABO identical human allogenic hepatocytes over a period of 5 h. Hepatocytes were transplanted at a concentration of 14 million/ml for a total infused volume of 280 ml. Doppler portal vein ultrasound and intraportal pressure were monitored during cell infusion. The procedure was complicated, 8 h after termination, by the development of portal vein thrombosis with liver failure and death of the patient. Autopsy showed occlusive thrombosis of the intrahepatic portal vein branches; cells or large aggregates of epithelial elements (polyclonal CEA positive), suggestive for transplanted hepatocytes, were co-localized inside the thrombus.     

Herpes zoster-associated idiopathic thrombocytopenic purpura in a liver transplant recipient: a case report and overview

Idiopathic (autoimmune) thrombocytopenic purpura has been previously reported as a rare complication in children and in a few adults following chickenpox. We report a case of varicella zoster virus-associated idiopathic thrombocytopenic purpura in an adult liver transplant recipient following dermatomal zoster. Idiopathic thrombocytopenic purpura developed 3 days after the onset of herpes zoster in our patient, with a nadir platelet count of 3000/mm³. The patient was treated with intravenous gamma globulin with recovery of thrombocytopenia after 3 weeks. Transplant clinicians need to be aware that this serious and potentially life-threatening complication may occur with herpes zoster in transplant recipients.     

Preservation of the recipient inferior vena cava in liver transplantation

Abstract Twenty piggy-back (PB) liver transplantations (LT) were compared with 20 LT performed by the standard technique in order to evaluate whether or not the theoretical haemodynamic advantages of the preservation of the inferior vena cava (IVC) have any impact on the final results of the LT. Statistically significant differences were observed in the duration of the hepatectomy, which was longer for PB LT (192 min vs. 146 min), and in the duration of the anhepatic phase, which was shorter in that group (52 min vs. 76 min). There were no differences in the duration of the complete surgical procedure, consumption of blood products, incidence of postoperative acute renal failure, number of reoperations or survival.     

保存不同时间的大鼠部分肝脏移植后的肝细胞再生

目的 探讨保存不同时间的大鼠部分肝脏移植后的肝细胞再生及其可能机制.方法 采用近交系雄性Lewis大鼠为供、受者,按照实验设计分别将供肝于4℃UW液中保存1 h(冷缺血1 h组)、8 h(冷缺血8 h组)和16 h(冷缺血16 h组).然后进行原位肝移植.移植肝恢复血流前,用3-0丝线结扎供肝左侧中央叶、左外叶及尾状叶,保留右侧的肝叶.即可制成大鼠50%体积肝脏(以下简称"半肝")原位移植模型.术后观察各组移植肝的存活情况和肝细胞再生情况;采用逆转录聚合酶链反应测定肝组织中自细胞介素-6(IL-6)和肿瘤坏死因子α(TNF_n)的表达情况;采用Western印迹法检测肝组织中信号传导与转录因子-3(STAT-3)表达情况;采用免疫组织化学染色检测移植肝组织中细胞周期素DI(Cyelin D1)的表达和肝细胞摄取溴脱氧尿核苷(BrdU)情况.结果 各组手术成功率均为100%.与冷缺血1 h组相比,冷缺血8 h组和冷缺血16 h组移植肝组织中TNF-a(F=67.45,P<0.05)和IL-6(F=287.73,P<0.05)的表达明显增加.STAT-3的表达也明显增强.肝移植后24 h.冷缺血8 h组在胞浆和细胞核内均有Cyclin D1的表达.而冷缺血16 h组移植肝组织中未见明显的Cyclin D1表达.移植后24 h.冷缺血16 h组的BrdU染色阳性的肝细胞数无明显增多,而在冷缺血8 h组可见BrdU染色阳性的肝细胞明显增多(t=19.40,P<0.05).结论冷保存一定时限的大鼠部分肝脏在移植后可获得肝细胞再生,此过程可能通过TNF-α/IL,16/sTAT-3/Cyclin D1/DNA合成的途径进行调节;当冷保存时间达16 h后,肝细胞不能对肝脏再生早期信号起反应.     

西罗莫司在肝移植术后钙调素类抑制剂相关肾损病人中的应用

目的 探讨西罗莫司对肝移植术后钙调素类免疫抑制剂相关肾功能损害病人的肾功能的改善作用及安全性.方法 对11例肝移植术后出现钙调素类免疫抑制剂相关肾损害病人进行西罗莫司转换治疗,同时减少或完全停止钙调素类免疫抑制剂的应用.观察转换治疗后病人的肾功能、肝功能、急性排斥反应的发生及药物副作用等情况.结果 随访至今所有病人均存活,随访时间6～23个月.转化治疗后所有病人的肾功能均有不同程度的改善,6个月后血肌酐从(163.8±47.9)μmol/L降为(108.1±26.6)μtmol/L(P<0.05);除1例病人出现转氨酶升高,加用钙调素类免疫抑制剂后恢复正常外,其余病人肝功能无明显变化;药物副作用有高脂血症、贫血、溃疡型口疮等.结论 西罗莫司可以安全地应用于肝移植术后钙调素类免疫抑制剂相关肾功能损害的病人,改善病人的肾功能,同时对移植肝功能无明显影响.     

肝移植术后肝动脉血栓形成的溶栓治疗3例报道

目的 探讨肝移植术后肝动脉血栓形成的溶栓治疗价值。方法对50例同种异体肝移植病例，术后以彩色多普勒超声(CDI)定期监测肝动脉血流，怀疑肝动脉血栓形成(HAT)行动脉造影，确诊3例，即刻行介入溶栓治疗，经导管分别在20分钟内予尿激酶12．5万单位、30分钟内予尿激酶25万单位和肝素50mg，及4小时内注入尿激酶60万单位。结果3例溶栓治疗后，肝动脉均再通。1例因二次血栓形成再次溶栓成功。但均发生不同程度的腹腔内出血，1例保守治疗痊愈，1例经开腹手术止血后痊愈，另1例死于多器官功能衰竭。结论对怀疑HAT病例，应尽早行动脉造影。改进后的溶栓疗法有可能成为治疗HAT的可选择方法。