肝移植术后感染病原菌分布及耐药性分析

目的 分析肝移植术后感染病原菌分布及耐药性,为临床合理应用抗菌药物提供科学依据。方法 对2014年3月—2021年12月青岛大学附属医院904例肝移植术后感染患者送检的各类标本分离出的病原菌分布及耐药性进行分析。采用WHONET 5.6软件对菌株列表及细菌耐药率进行统计;采用Excel对标本来源、构成比及病原菌分布情况等进行统计分析。结果 共分离出非重复性病原菌2 208株,主要分离自呼吸道(31.25%)、胆汁(22.28%)、腹水(13.18%)、血液(8.38%)和引流液(4.62%),前10位病原菌为肺炎克雷伯菌肺炎亚种(10.69%)、屎肠球菌(10.42%)、大肠埃希菌(8.24%)、铜绿假单胞菌(8.24%)、表皮葡萄球菌(8.06%)、鲍曼不动杆菌(7.93%)、嗜麦芽窄食单胞菌(6.61%)、阴沟肠杆菌(3.22%)、溶血葡萄球菌(3.08%)和金黄色葡萄球菌(2.94%),共占比69.43%。呼吸道标本的主要致病菌为铜绿假单胞菌、嗜麦芽窄食单胞菌、肺炎克雷伯菌肺炎亚种和鲍曼不动杆菌,胆汁、腹水和引流液标本的主要致病菌为屎肠球菌,血液标本的主要致病菌为大肠埃希菌、表皮...     

肝移植术后胆道并发症的防治和围手术期处理

我国许多肝移植中心的手术成功率超过90％,5年生存率大于70％,移植效果已与国际先进水平接轨。在长期的临床实践和术后随访中,我们认识到肝移植术后的各种并发症仍然是阻碍受体生存率及移植肝存活率进一步提高的重要原因,尤其是胆道并发症的发生,     

肝移植术的常见并发症及处理

目前肝移植在手术技术以及围手术期处理上已基本成熟，并已成为终末期肝病及暴发性肝炎的常规治疗手段。尽管如此，肝移植术后形形色色的并发症仍难以避免，严重时可造成移植物丢失和受者死亡。因此移植术后并发症的成功防治成为提高肝移植受者生存率的重要条件。现将肝移植术后常见并发症的临床表现、诊断、处理做一简要的介绍。     

原位肝移植术后心血管并发症的临床处理

目的 总结肝移植术后常见的心血管系统并发症及其可能的原因和防治方法。方法 对中山大学第一附属医院1993年4月至2001年12月间的肝移植病例住院期间术后近期发生的心血管系统并发症进行回顾性分析。结果 88位患者实施了89例次肝移植,65例患者发生心血管系统并发症,同心血管并发症相关的病死率为12.4％(11/89)。术后凝血功能紊乱可能是发生心肌缺血的主要原因;心力衰竭程度随术中输血量不同差异有显著性(x~2=5.714,P<0.05);术后高血压的发生与多种因素有关。结论 心血管系统并发症是肝移植术后常见的和严重的并发症之一,并有较高的病死率。合适的病例选择,维持凝血机制及出入量的平衡是降低术后心血管并发症的关键。     

血清降钙素原水平在肝移植术后并发肺部感染患者中的诊断价值

目的探讨降钙素原(PCT)的检测对肝移植术后细菌性中老年肺炎患者临床诊断价值。方法回顾性分析该院22例行肝脏移植术后并发肺部感染的中老年患者,将其分为细菌性肺炎感染组和非细菌性肺炎感染组。提取两组患者发热初期及48 h血清,检测PCT和C反应蛋白(CRP)浓度,采用受试者工作特征曲线(ROC)评价并比较两组敏感性和特异性差异。结果 PCT在肝移植术后并发细菌性肺炎患者与非细菌性肺炎患者中的水平有统计学差异(P0.05),CRP水平无统计学差异(P0.05)。ROC曲线表明细菌性肺炎组和非细菌性肺炎组发热初期PCT和CRP敏感性及特异性均较差;但患者病情发展48 h后,PCT比CRP表现出更好的敏感性和特异性(100%vs 86%,87%vs 71%,P0.05)。结论 PCT比CRP更能灵敏地检测到肝移植术后患者细菌性肺炎的发展及预后。     

肝移植术后非感染性肺部并发症原因及其防治

肝移植现已被广泛应用于肝硬化、Wilson病、肝细胞肝癌等的治疗,术后出现的肺部并发症非常常见,且对术后肝功能的恢复及围手术期病死率有重要影响。现重点针对肝移植术后的非感染性肺部并发症——胸腔积液、急性肺水肿、急性呼吸衰竭、肺不张的原因及其防治作一综述。     

肝移植术后乙型肝炎病毒再感染的防治

目前，我国的肝移植临床工作正在蓬勃开展，每年移植的患者已逾千例。然而，在进行肝移植的患者中，绝大多数是乙型肝炎(乙肝)相关的晚期肝病，如何防止移植术后HBV的再感染就成了我国移植工作者面临的重要课题。     

Bacterial infection after liver transplantation

Infectious complications are major causes of morbidity and mortality after liver transplantation, despite recent advances in the transplant field. Bacteria, fungi, viruses and parasites can cause infection before and after transplantation. Among them, bacterial infections are predominant during the first two months post-transplantation and affect patient and graft survival. They might cause surgical site infections, including deep intra-abdominal infections, bacteremia, pneumonia, catheter-related infections and urinary tract infections. The risk factors for bacterial infections differ between the periods after transplant, and between centers. Recently, the emergence of multi-drug resistant bacteria is great concern in liver transplant (LT) patients. The instructive data about effects of infections with extended-spectrum beta lactamase producing bacteria, carbapenem-resistant gram-negative bacteria, and glycopeptide-resistant gram-positive bacteria were reported on a center-by-center basis. To prevent post-transplant bacterial infections, proper strategies need to be established based upon center-specific data and evidence from well-controlled studies. This article reviewed the recent epidemiological data, risk factors for each type of infections and important clinical issues in bacterial infection after LT.     

Low-dose amphotericin for prevention of serious fungal infection following liver transplantation

AIMS: This study advances previously performed clinical studies of antifungal prophylaxis and prospectively evaluates the efficacy of low-dose amphotericin B preparations for the prevention of invasive fungal infection (IFI) in high-risk liver transplant (LT) recipients. METHODS: High-risk LT patients were recruited and randomised to openly receive intravenously either conventional amphotericin B (amB) at a dose of 15 mg daily, or liposomal amphotericin B (amBisome) 50 mg daily. Prophylaxis was continued until discharge from the intensive care unit (ICU), until patient death, or until time of conversion to high-dose amBisome for treatment of suspected or confirmed IFI. RESULTS: During the study period, 360 adult LTs were performed; 132 patients were eligible for 149 recruitment episodes into the trial, and 83 patients were recruited for 92 episodes. Of the 92, 48 patient episodes were randomised to receive amBisome prophylaxis, and 44 to receive amB. IFI was uncommon, diagnosed for 3 patients in the amBisome group, and for 2 in the amB group. Furthermore, Aspergillus was isolated on a single occasion during 92 episodes of prophylaxis. Fungal colonisation scores did not differ significantly between the 2 groups. There was a significant difference in the rates of survival to ICU discharge between the 2 groups (79.6% amBisome vs. 59.5% amB, P=0.038). Renal function measures including creatinine clearance at commencement and conclusion of prophylaxis, and at 12 months post transplant were not statistically different between the 2 groups. CONCLUSION: The use of amphotericin B, liposomal or non-liposomal preparations at low doses, for prophylaxis of IFI in high-risk LT patients, is associated with a low incidence of serious fungal infection. In this randomised study, low-dose amBisome prophylaxis was associated with an increased likelihood of successful discharge from the ICU.     

伊曲康唑与氟康唑预防肝移植术后侵袭性真菌感染疗效比较

目的 比较伊曲康唑口服液和氟康唑胶囊预防肝移植术后侵袭性真菌感染的有效性和安全性。方法 本试验为随机、对照、开放的临床试验。入选的60例肝移植术后患者随机分为两组。试验组（30例）使用伊曲康唑口服液预防肝移植术后真菌感染,20ml,1次／d,空腹服用;对照组（30例）使用口服氟康唑胶囊预防肝移植术后真菌感染,0．15g,1次/d;两组均常规使用15d,在服药期间观察两组患者真菌感染的发生情况和药物敏感情况。结果 伊曲康唑口服液组服药期间有3例发生真菌感染,感染率为10．0％,其中确诊1例,临床诊断2例。氟康唑胶囊组10例发生真菌感染,感染率为33．3％,其中确诊2例,临床诊断6例,拟诊2例。两组患者真菌感染率差异有统计学意义（P〈0．05）,用药前及用药后两组患者肝肾功能指标差异均无统计学意义（P〉0．05）。结论 伊曲康唑口服液较氟康唑胶囊能更有效地预防肝移植术后侵袭性真菌感染,且两者的安全性相当。     

Microbiological findings of culture‐positive preservation fluid in liver transplantation

S. Janny, F. Bert, F. Dondero, F. Durand, P. Guerrini, P. Merckx, M.H. Nicolas‐Chanoine, J. Belghiti, J. Mantz, C. Paugam‐Burtz. Microbiological findings of culture‐positive preservation fluid in liver transplantation.
Transpl Infect Dis 2011: 13: 9–14. All rights reserved Abstract: Bacterial and fungal infections are the leading cause of mortality in liver transplant (LT) recipients. Few studies have examined the incidence of culture‐positive preservation fluid (PF) and the outcome of related recipients. The aim of this study was to determine the incidence and the microbiologic findings of PF positive cultures, and to evaluate the impact on morbidity and mortality of LT recipients. A retrospective analysis of PF cultures performed after 477 LTs from cadavaric grafts between January 2001 and February 2008 was conducted. Forty‐five (9.5%) PFs were found to be positive with 1 or 2 pathogens. The demographic profiles of recipients of PF with positive or negative cultures were similar. Enterobacteriaceae species were the most frequent organisms (n=30), followed by Staphylococcus aureus (n=5), coagulase‐negative staphylococci (n=5), enterococci (n=4), and yeasts (n=3). Mortality rate at 1 month was not significantly different in recipients with positive or sterile PF cultures (88.1% vs. 87.7%, respectively). The rate of bacteremia among LT recipients with positive or negative PF cultures was not statistically different. Systemic infections caused by the pathogen cultured from the PF occurred in 8 (18%) of the 45 recipients, including bacteremia (4/8) or intra‐abdominal sepsis (5/8). Causative organisms were Enterobacteriaceae species (n=5), Candida species (n=2), and Enterococcus faecium (n=1). Among the 8 patients who developed infection with the PF organism, 4 (50%) died in the intensive care unit (ICU) vs. an ICU mortality rate of 8% (3/37) in those who did not develop infection with the PF organism (P<0.05). Infection occurred less frequently in recipients who received antimicrobial therapy with activity against the PF isolate than in those without appropriate treatment (41% vs. 3.8%, P<0.005). Those who develop infection with organisms recovered from PF cultures appear to have high early mortality rates; therefore, appropriate antimicrobial therapy against organisms cultured from PF should be given.     

非生物人工肝联合肝移植治疗中晚期慢性重型肝炎

目的评价非生物人工肝支持系统（ALSS）联合肝移植治疗巾晚期慢性重型肝炎的临床应用价值。方法采用ALSS联合肝移植治疗28例中晚期慢性重型肝炎患者，观察治疗前后各项临床指标的变化与疗效，并就治疗后生存率与同期内科治疗组99例患者、内科联合ALSS治疗组30例患者比较。数据行t和x^2检验。结果28例患者共成功进行57次ALSS治疗，TBil、PT、胆汁酸、BUN、Cr、血氨等指标明显好转（P〈0．05），临床症状改善的中位时间为3d（1～153d）。28例均顺利完成肝移植术，等待到供肝的中位时间为20d（1～153d），术后3、6个月生存率（71．d％，71．4％）显著高于内科治疗组（18．2％，11．1％）和内科联合ALSS治疗组（36．7％，26．6％）（P〈0．01）。结论术前应用非生物人工肝治疗，可有效改善中晚期慢性重型肝炎患者的病情，为顺利过渡到肝移植发挥桥梁支持作用。人工肝联合肝移植是有效治疗中晚期慢性重型肝炎的可靠方法。     

2008年肝移植内科问题的研究进展

作为一个器官的疾病,终末期肝脏疾病的处理包括了内科和外科的处理,肝移植也一样涉及到内科和外科.     

Fluoroquinolones for the treatment of latent Mycobacterium tuberculosis infection in liver transplantation

Solid organ transplantation(SOT)is the best treatment option for end-stage organ disease.Newer immunosuppressive agents have reduced the incidence of graft rejection but have increased the risk of infection,particularly due to the reactivation of latent infections due to opportunistic agents such as Mycobacterium tuberculosis.Active tuberculosis(TB)after SOT is a significant cause of morbidity and mortality.Most cases of posttransplant TB are secondary to reactivation of latent tuberculosis infection(LTBI)due to the effects of long-term immunosuppressive therapy.Risk minimization strategies have been developed to diagnose LTBI and initiate treatment prior to transplantation.Isoniazid with vitamin B6 supplementation is the treatment of choice.However,liver transplantation(LT)candidates and recipients have an increased risk of isoniazid-induced liver toxicity,leading to lower treatment completion rates than in other SOT populations.Fluoroquinolones(FQs)exhibit good in vitro antimycobacterial activity and a lower risk of drug-induced liver injury than isoniazid.In the present review,we highlight the disease burden posed by posttransplant TB and summarize the emerging clinical evidence supporting the use of FQs for the treatment of LTBI in LT recipients and candidates.