供受体ABO血型不合肝移植

目的 探讨供受体ABO血型不合肝移植的治疗及效果.方法 回顾性分析武警总医院实施的9例ABO血型不合肝移植临床资料.1例病人术前行血浆置换.全部病例术中均采用显微镜下吻合肝动脉和胆道,5例病人术中切除了脾脏.全部病例采用了四联免疫治疗方案.术后注意保持氧饱和度大于95%,并加强抗凝治疗.结果 4例病人顺利恢复,无并发症.其余5例中,3例出现急性排斥反应,4例出现胆道非吻合口狭窄,3例病死.结论 当供体缺乏而受者病情不能等待时,可以进行供受体ABO血型不合肝移植,但应该尽量减少并发症发生.     

ABO血型不相容肝移植策略

随着器官移植的高速发展,全球性器官短缺问题日益凸显。肝移植是目前治疗终末期肝病最有效的手段,但供者短缺一直是制约肝移植发展的关键问题,我国是乙型病毒性肝炎大国,供肝短缺问题尤为显著,很多危重症患者往往因为无法及时获得匹配的供肝,而失去最佳时机甚至死亡。ABO血型不相容（ABOi）肝移植作为一种扩大供者资源的策略,为那些等待合适供者的患者提供了新的希望。然而,由于ABOi肝移植术后更容易发生严重感染、抗体介导的排斥反应（AMR）、胆道并发症、血栓性微血管病以及急性肾损伤等并发症,因此备受争议。本文综述了ABOi肝移植的术前、术中和术后策略研究进展,旨在为ABOi肝移植临床应用及研究提供参考。     

ABO血型不同供肝肝移植的临床应用

目的：探讨供受体ABO血型不同肝移植的治疗及效果。方法：回顾性分析15例ABO血型不同肝移植临床资料。血型相容的6例采用常规治疗。血型不相容的9例均于术中显微镜下吻合肝动脉和胆道,术后采用四联免疫治疗方案及抗凝治疗,其中1例术前行血浆置换,5例术中切除脾脏。结果：血型相容的6例无并发症出现。血型不相容的9例中,4例患者顺利恢复,无并发症;其余5例中,3例出现急性排异反应,4例出现胆道非吻合口狭窄,3例死亡。结论：ABO血型不同但相容的供肝肝移植效果良好,血型不相容的供肝肝移植并发症多。当供体缺乏而受者病情不能等待时,可以选择性进行,但应该尽量减少并发症发生。     

肝移植中应用ABO血型不合供肝的初步经验

目的 探讨急诊状况下ABO血型不合肝移植的疗效及其预后影响因素.方法 410例原位肝移植中有8例为ABO血型不合的急诊肝移植,其中受体血型O型5例、非O型3例.术后以四联免疫抑制剂抗排斥反应,观察受体急性排斥反应、血管、胆道并发症、感染和肝肾功能情况.结果 患者半年存活率为50%,围手术期死亡率为50%.受体血型O型和非O型、MELD（model for end-stage liver disease）评分＜30分和≥30分、CTP（Child-Turcotte-Pugh）评分＜13分和≥13分、重型肝炎和非重型肝炎、脾切除和非脾切除患者的半年存活率分别为80%和0%、50%和33%、75%和25%、25%和75%、33%和60%.术后并发症有：急性排斥反应1例;胆漏1例;肝叶坏死和肝脓肿2例;肾功能衰竭2例;感染6例（2例为曲霉菌感染）.结论 ABO血型不合肝移植预后不佳,围手术期死亡率高,因此仅适用于无法及时获得合适供肝的急诊肝移植.     

ABO血型不合的供肝在肝移植中的应用

目的 探讨AB0血型不合的供肝肝移植后的临床治疗措施、疗效及预后.方法 2004年1月至2008年1月接受原位肝移植的2188例患者中,有16例为ABO血型不合的肝移植.术前及术后监测此16例患者的血液凝集素效价;术后采用四联免疫抑制方案抗排斥反应;术中有5例行脾切除.术后观察受者的肝功能、急性排斥反应、血管和胆道并发症及术后存活率.结果 患者围手术期死亡率为25%(4/16),半年存活率为75%(12/16),1年存活率为37.5%(6/16).术后发生急性排斥反应3例、感染5例、多器官功能衰竭1例和胆道并发症1例.结论 ABO血型不合的肝移植多在紧急状况下实施,患者预后不佳.通过术前及术后综合防治措施,可以减少术后排斥反应的发生.提高存活率.     

供受体ABO血型不合的肝移植围手术期处理

目的:探讨供受体ABO血型不合肝移植围手术期的处理方法及疗效。方法:回顾性分析我院实施的13例ABO血型不合肝移植的临床资料,对围手术期可能出现的并发症进行针对性预防,主要采用的措施包括血浆置换、术中显微镜下吻合肝动脉和胆道、切除脾脏、四联免疫抑制治疗,以及术后保持氧饱和度>95%、加强抗凝、预防感染等。结果:13例患者中,7例恢复良好,未出现并发症,其余6例患者中有3例出现急性排异反应,4例出现胆道非吻合口狭窄,4例死亡。结论:在供体缺乏而受者病情危急时,进行供受体ABO血型不合的肝移植是可行的,加强围手术期处理,有助于减少术后并发症,提高肝移植的疗效。     

供、受者间ABO血型不合的活体肝移植进展

由于目前尚无类似人工肾的肝脏替代疗法，在急性肝功能衰竭等紧急情况下，如果等待血型相符的供肝，患者很可能会失去治疗机会。因此，而在目前临床肝移植中，ABO血型不合仍占有一定的比例。在北美，ABO血型不合的肝移植占成人肝移植的24％，占小儿肝移植的69％；在欧洲，8％的急诊肝移植为ABO血型不合者。近年来，随着活体肝移植的开展，供、受者ABO血型不合的情况也屡有出现，现对ABO血型不合的活体肝移植的进展作一综述。     

供受体血型不合肝移植可行性探讨

目的 探讨供受体血型不合肝移植治疗重症肝炎的可行性。方法 回顾性分析2004年7月上海交通大学医学院附属新华医院收治的1例O型血重症肝炎病人接受B型血供肝的临床病例资料。采用四联免疫抑制药物治疗，激素减量延迟。结果病人术后恢复顺利，未发生排斥反应，已健康存活17个月。结论 供受体ABO血型不合肝移植可以作为抢救重症肝炎病人的选择，尤其对O型血受体疗效较好。     

儿童ABO血型不相容活体肝移植术后供者血型抗原不完全免疫耐受状态的研究

目的结合临床数据及文献分析儿童ABO血型不相容活体肝移植针对血型抗原低免疫应答状态的潜在免疫机制。方法回顾性收集首都医科大学附属北京友谊医院2013年6月至2020年12月期间施行的术后长期生存的儿童ABO血型不相容活体肝移植受者29例, 受者血型均为O型, 其中A型供者10例, B型供者19例。移植物类型包括左外侧叶26例, 左半肝3例;肝移植手术中位年龄10月龄, 中位体重为8.0 kg, 中位随访时间41.9个月。连续监测移植术前及移植术后1、3、6、12、24、36个月受者体内针对供者血型相关抗体与供者血型非相关抗体滴度(IgG、IgM), 并进行比较分析。对纳入受者进行程序性肝脏病理穿刺活检或事件性肝脏病理穿刺活检判断是否存在抗体介导排斥反应。结果受者移植术前及术后血型抗体(IgG、IgM), 受者体内抗供者血型相关抗体滴度呈持续低水平状态, 较体内非供者血型相关抗体滴度水平显著降低, 差异有统计学意义(P<0.001)。对于纳入研究的29例受者, 共有18例完成程序性肝脏病理活检, 其中2例提示血管内皮C4d阳性;5例完成肝功能异常事件性肝脏病理活检, 其中1例存在胆...     

ABO血型不合肝移植研究进展

根据供／受体ABO血型配合情况，可以将其分为ABO血型相同、ABO血型相符和ABO血型不合。数据统计表明：ABO血型不合肝移植术后发生急性排斥反应、肝叶坏死和血管、胆道并发症均较血型相符者多。但是，肝脏作为一“免疫特惠器官”，对抗体介导的损伤有较好的耐受性，极少发生超急性排斥反应。匹兹堡UNOS肝移植登记处的资料显示，7000余例成人肝移植中ABO血型不合者占3％，在1500例小儿肝移植中占7％。在欧洲，8％的急诊肝移植为ABO血型不合。因此，在紧急或供体紧缺的情况下行ABO血型不合的肝移植已逐渐被接受。     

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目的 探讨ＡＢＯ配对肝移植预后的影响。方法 回顾分析３例ＡＢＯ血型不合的肝脏移植临床特点及治疗结果。结果 ２例病人出现不可逆性斥反应，分别于术后第１８、２０天死亡，１例病人未出现排斥反应，现已存活１５０天。结论 ＡＢＯ配型不合对肝移植的预后可能有很大影响，目前仅限于在紧急状态下采用。     

ABO血型不合肝移植研究新进展

复习国外文章关于ABO血型不相同的肝脏移植在A2型供肝使用,移植肝出现受体类型的ABO组织血型抗原,C4d作用和临床治疗上的新进展。A2型供肝能较安全的用于血型不合肝移植,毛细血管内表达r-ABOAg可能是移植物内皮损害和修复的表现,C4d阳性对血型不同肝移植治疗策略上是很好的参考物,但缺乏特异性,采用包括多联免疫抑制药和肝内灌注等综合治疗方法能有效预防排斥反应且能取得良好的预后。     

Feasible usage of ABO incompatible grafts in living donor liver transplantation

Background

The use of ABO incompatible (ABOi) graft in living donor liver transplantation (LDLT) has not been an established procedure worldwide.

Methods

Four hundred and eight adult LDLTs, using ABOi (n=19) and non-ABOi (n=389) grafts, were performed as a single center experience.

Results

In ABOi-LDLT group (n=19), median isoagglutinin titer before plasma exchange (PE) at LDLT and after LDLT (max) was ×256, ×32 and ×32, respectively. Rituximab was given at 21.8±6.1 days before LDLT and PE was performed 3.7±1.6 times. Although ABOi-LDLTs had increased rate of splenectomy (89.4% vs. 44.7%, P<0.001) and lower portal venous pressure (PVP) at the end of surgery (13.8±1.1 vs. 16.9±0.2 mmHg, P=0.003), other operative factors including graft ischemic time, operative time and blood loss were not different between the groups. Although ABOi-LDLTs had increased incidence of cytomegalovirus infection (52.6% vs. 22.9%, P=0.007), other post-transplant complications including bacterial sepsis and acute rejection were not different between the groups. The 5-year graft survival rate was 87.9% in ABOi-LDLTs and 80.3% in non-ABOi-LDLTs (P=0.373).

Conclusions

ABOi-LDLT could be safely performed, especially under rituximab-based protocol.     

Successful ABO-incompatible heart transplantation in two infants

In the pediatric age group shortage of donor hearts leads to mortality rates of 30-50% on the waiting list. Because of the immaturity of the immune system of infants, ABO-incompatible heart transplantation may be an option to increase donor availability. We transplanted two infants with blood type O at the age of 7 and 5 months, respectively, with complex congenital heart disease. Intraoperative plasma exchange was performed during cardiopulmonary bypass followed by standard immunosuppression. Both recipients received a blood type A donor organ. Plasma was exchanged up to six times until anti-A antibodies were eliminated. No hyperacute rejection occurred, ventricular function is excellent and there have been no acute rejection episodes up to 4 months after transplantation. Anti-A antibody titers remained low and eventually disappeared. ABO-incompatible cardiac transplantation shows good short-term results in young infants and appears to be a safe procedure to reduce mortality on the waiting list.     

Pathogenesis in ABO incompatible liver transplantation: a clinicohistological evaluation of four patients

Takeda K, Tanaka K, Morioka D, Kumamoto T, Endo I, Togo S, Shimada H. Pathogenesis in ABO incompatible liver transplantation: a clinicohistological evaluation of four patients.
Clin Transplant 2010: 24: 747–751. © 2009 John Wiley & Sons A/S. Abstract: The aim of this study was to clarify the pathogenesis of antibody‐mediated rejection (AMR) of ABO‐incompatible liver transplantation (ABO‐I‐LT). We investigated, within one month of surgery, the clinical courses of 10 patients who received ABO‐I‐LT. We encountered four cases of AMR, which were classified into two groups according to the stage of the AMR: early (within the first 14 postoperative days [PODs]) or late (after the 14th POD). There were three patients in the early stage, and one patient in the late stage. Three early‐stage AMR patients had both hyperbilirubinemia and thrombocytopenia within one month after LDLT, but the one late‐stage AMR patient had neither. On liver biopsy, hemorrhagic infiltration was seen more frequently in the early‐stage AMR patients than in the patient with late‐stage AMR. Plasma exchange combined with a large amount of gamma‐globulin bolus infusion therapy was effective in the three early‐stage patients, but the late‐stage AMR was controlled by antibiotic treatment. This study showed that the early‐stage AMR resulted from the antigen‐antibody reaction of ABO‐blood‐group antigens, while the late‐stage AMR may have been caused by an infection.     

Risk factors for portal vein complications in pediatric living donor liver transplantation

Shibasaki S, Taniguchi M, Shimamura T, Suzuki T, Yamashita K, Wakayama K, Hirokata G, Ohta M, Kamiyama T, Matsushita M, Furukawa H, Todo S. Risk factors for portal vein complications in pediatric living donor liver transplantation.
Clin Transplant 2010: 24: 550–556.
© 2009 John Wiley & Sons A/S. Abstract: Background: Portal vein (PV) complications in pediatric living donor liver transplantation (LDLT) are often asymptomatic in the early stages after transplantation and can be serious enough to lead to graft failure. There have been few reports on risk factors for PV complications in LDLT. The aim of this study is to investigate the influence of hepatic inflow upon PV complications and to predict patients at risk for these complications. Material/method: From 1997 to 2008, 46 pediatric patients underwent LDLT at our center. Portal venous and hepatic arterial flows and PV diameter were analyzed. Results: PV complications were identified in seven patients (15.2%) and occurred at a younger age and lower weight. As a result of appropriate treatment, none of the patients suffered graft failure. Analysis of the 46 patients and 27 patients under two yr of age indentified smaller PV diameter in recipient and larger discrepancy of PV diameter as risk factors. Portal venous flow tended to be low, in contrast to hepatic arterial flow, which tended to be high. Conclusion: PV size strongly influences PV complications. Other factors such as younger age, low portal venous flow, and high hepatic arterial flow may be risk factors for PV complications.     

Long-term follow-up ABO-incompatible adult living donor liver transplantation in cirrhotic patients

ABO-incompatible liver transplantation is usually contraindicated. The presence in the recipient of preformed anti-A/B antibodies located on endothelial cells raises the risk of antibody-mediated humoral rejection of the graft. We describe four successful cases of steroid withdrawal in adult patients who had living-donor liver transplantation from ABO-incompatible donors. Antirejection therapy included multiple perioperative plasmapheresis, splenectomy, and a triple immunosuppressive regimen with tacrolimus, methylprednisolone (MPSL), and cyclophosphamide or mycophenolate mofetil (MMF). The maintenance dose of immunosuppression did not differ from that of ABO-identical cases. After transplantation, intrahepatic arterial infusion therapy with prostaglandin E1 (PG E1) was used. As a result, all four patients were able to achieve long-term graft survival without steroid use. They all have good liver function and are leading normal lifestyles. Our experience with these four patients suggests the feasibility of controlling humoral rejection and other complications in adult ABO-incompatible living donor liver transplantations with intrahepatic arterial infusion of PGE1, splenectomy, and plasmapheresis with a regular base of immunosuppression protocol to prevent antibody-mediated humoral rejection.