原位肝移植术后细菌感染的防治

目的 探讨原位肝移植术后细菌感染的特点、易感因素,总结防治经验。方法 回顾性分析我院79例原位肝移植的临床资料,对感染部位、常见致病菌、耐药情况和导致细菌感染的危险因素进行分析。结果 全组32例发生细菌感染,感染率为40．5％,感染部位以肺部、腹腔及血液多见。感染菌株中以大肠埃希菌、金黄色葡萄球菌、肺炎克雷伯杆菌、表皮葡萄球菌及肠球菌为主。恢复饮食时间延长（〉5d）、术前肝功能C级、低蛋白血症及术后持续高血糖（〉11．0 mmol/L）是感染的危险因素,肠道去污治疗是预防细菌感染的保护性因素。结论 肝移植术后细菌感染是严重并发症之一,尽可能地减少各种危险因素,有效预防及早期确诊和治疗是防治细菌感染的关键。     

老年患者肝移植术后感染的病原学和耐药性分析

目的 探讨老年（≥60岁）患者肝移植术后感染的病原学、耐药性特点和相关的易感因素。方法 回顾性分析57例老年患者肝移植后的临床资料,对其术后发生感染的易感因素、发生率、发生部位、病原学特征、耐药性及感染死亡率进行总结。结果 57例老年肝移植患者中有40例（70．18％）术后发生感染,其中30例为混合性细菌感染,15例合并深部真菌感染,感染以多部位混合感染最为常见。经积极治疗,37例患者存活,存活率为64．91％;感染导致死亡9例,占死亡人数的45％;术后感染治愈率为77．5％。致病菌以屎肠球菌、耐甲氧西林凝固酶阴性葡萄球菌、嗜麦芽寡单胞菌、耐甲氧西林金黄色葡萄球菌、白色念珠菌等最为常见,其中大多数革兰氏阳性球菌对万古霉素、替考拉宁敏感,对其他常用药普遍耐药革兰氏阴性杆菌对亚安培南、美罗培南的耐药株多;对头孢三代普遍耐药;对头孢四代、喹诺酮类等敏感性高于其他药物。真菌对两性霉素B均敏感,但多数对酮康唑、益康唑、氟康唑耐药。结论 老年肝移植术后具有高感染率、高耐药率、高致死率等特点,应引起注意。     

公民逝世后器官捐献供肝肝移植术后感染特点及危险因素分析

目的探讨公民逝世后器官捐献供肝肝移植受体术后感染特点及感染相关危险因素。方法回顾性分析接受公民逝世后器官捐献供肝肝移植68例受体的临床资料。根据受体术后是否合并感染分为感染组(33例)和非感染组(35例)。总结68例肝移植受体术后感染的主要特点;对受体发生肝移植术后感染的可能危险因素进行单因素分析;有统计学意义的危险因素再进行多因素分析,找出独立危险因素,并采用受试者工作特征(ROC)曲线分析其预测肝移植术后感染的准确度。结果肝移植术后33例受体发生感染,占总数的49%,以细菌感染和真菌感染为主,感染部位主要有肺部感染和腹腔感染。单因素分析发现,供体存在开放性损伤,受体术前血红蛋白水平、血小板计数、肝功能Child-Pugh分级、终末期肝病模型(MELD)评分,术中红细胞输注量,术后第1日γ-谷氨酰转肽酶(GGT)、重症监护室(ICU)停留时间共8个因素是器官捐献供肝肝移植术后感染的相关因素(均为P0.05)。多因素Logistic回归分析结果显示术前血红蛋白水平120 g/L和术后ICU停留时间96 h为器官捐献供肝肝移植术后感染的独立危险因素(均为P0.05)。ROC曲线分析显示,术前血红蛋白水平114 g/L和术后ICU停留时间102 h对预测术后感染准确度较高。结论公民逝世后器官捐献供肝肝移植术后感染发生率较高,以细菌感染和真菌感染为主,感染部位主要在肺部和腹腔。受体肝移植术前血红蛋白水平低及术后ICU停留时间长,会增加肝移植术后感染风险。     

肝移植术后的细菌感染

目的观察原位肝移植术后细菌感染的特点和相关因素，总结诊断和治疗经验。方法回顾分析我院2000年12月至2002年12月治疗的17例肝移植受体的细菌感染率、感染部位、常见致病菌和耐药情况。结果肝移植术后15例(88．2％)发生34次细菌感染，以肺部感染和腹腔感染多见。手术时间延长、伴随糖尿病及胆道狭窄的发生分别与腹腔、泌尿系和胆道细菌感染有关。多种细菌混合感染、院内感染、条件致病菌所致感染比例大，耐药菌株检出率高。结论细菌感染是肝移植术后的主要并发症之一，手术时间延长、伴随糖尿病及胆管狭窄的发生是细菌感染的相关因素。有效的预防、早期确诊和治疗是控制细菌感染的关键。     

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。     

103例肝移植术后细菌感染危险因素分析

目的分析肝移植病人术后各类细菌感染的发生率及其危险因素。方法回顾性分析四川大学华西医院2000~2003年施行的103例肝脏移植病人的临床资料。选取围手术期45个独立变量,经单变量分析及logistic回归分析,筛选与术后感染相关的危险因素。结果52例病人术后发生77次细菌感染,感染率为50·49%(52/103);G-需氧菌占67·8%(103/152),G 需氧菌占32·2%(49/152)。手术时间、呼吸机带机时间、TPN支持时间与术后早期细菌感染有关。结论肝移植术后易发生细菌感染,针对其危险因素积极采取预防措施是降低术后感染率的主要措施。     

再次肝移植术后早期与死亡率相关的危险因素分析

目的 探讨再次肝移植术后早期与死亡率相关的独立危险因素.方法 回顾性分析2004年1月至2007年12月间的36例再次肝移植的资料.根据再次肝移植术后早期(术后3个月内)的转归,将患者分为死亡组和存活组.收集两组患者术前及术中常用的15项临床或实验室指标作为可能影响死亡率的危险因素进行单因素分析,将有统计学意义的危险因素再进行Logistic回归分析,筛选出与术后早期死亡率相关的独立危险因素.结果 再次肝移植术后早期死亡率为25%(9/36),死亡原因为:严重感染5例(55.6%),急性肾功能衰竭2例(22.2%),心肌梗死和脑出血各1例(各11.1%).经单因素分析显示,死亡组和存活组间术前肌酐水平、终末期肝病模型评分、感染、重症监护室(ICU)监护时间、机械通气时间以及再次肝移植的手术时间和术中出血量的差异有统计学意义(P<0.05),Logistic多元回归分析显示,术前ICU监护时间和术中出血量是术后早期与死亡率相关的独立危险因素.结论 再次肝移植术前ICU监护时间和术中出血量与术后早期死亡率密切相关.     

儿童活体肝移植术后住院期间细菌感染的临床研究

目的 研究儿童活体肝移植术后细菌感染的常见病原菌种类、分布特征及耐药性.方法 回顾性分析41例儿童活体肝移植的临床资料,对受者术后住院期间的细菌感染发生率、感染发生时间、感染部位、病原菌种类和分布以及药敏试验结果进行总结.结果 41例肝移植受者中,有33例受者发生细菌感染69次,细菌感染发生率为80.5％(33/41).主要的感染部位依次是下呼吸道32例次(占46.6％)、腹腔16例次(占23.3％)及胆道11例次(占15.9％).共检出致病菌101株,其中革兰阴性菌(G-菌)占73.3％(74/101),超广谱β-内酰胺酶(ESBL)检出率为81.1％ (60/74);革兰阳性菌(G+菌)占26.7％(27/101),耐甲氧西林凝固酶阴性葡萄球菌(MRCNS)检出率为59.3％(16/27),氨基糖苷类高耐药肠球菌(HLAR)检出率为11.1％(3/27).术后2周内检出致病菌72株(71.3％).常见致病菌为铜绿假单胞菌、表皮葡萄球菌和大肠埃希菌等.致病菌对β-内酰胺类加酶抑制剂和头孢类的耐药率超过60％,主要的产ESBL的G-菌对碳青霉烯类敏感,耐药率＜10％;碳青霉烯类药物亚胺培南/西司他丁、美罗培能对质粒介导的ESBL、染色体及质粒介导的头孢菌素酶(AmpC酶)均具有高度稳定性;铜绿假单胞菌对碳青霉烯类和儿科常用抗生素均高度耐药,仅对喹诺酮类敏感;凝固酶阴性葡萄球菌和肠球菌对万古霉素、利奈唑胺、奎奴普丁/达福普丁高度敏感.结论 肝移植术后细菌感染发生率高,耐药菌株检出率高,且具有多重耐药特点.有效地预防感染,术后早期确诊和合理选用抗生素是控制细菌感染的关键.     

肝移植术后细菌感染的诊治

目前肝移植技术不断提高,但感染相关并发症仍是造成肝移植术后患者死亡的主要原因之一。细菌、病毒、真菌及寄生虫都有可能造成肝移植术后感染,其中以细菌感染为主。肝移植术后细菌感染的危险因素包括移植因素、受体因素和供体因素等。肝移植术后细菌感染通常在术后2个月内发生,其感染的优势菌群与院内感染的主要菌群、地域特点有关,但革兰阴性菌和革兰阳性菌是主要的感染病原体。肝移植术后细菌感染的预防分为术前、术中、术后3个阶段,围手术期48 h内使用抗生素尤为重要,预防性使用抗生素可以降低细菌感染的发生率。肝移植术后细菌感染是直接影响受体预后的重要因素之一,对于感染的控制宜采取以预防为主、防治结合的方式。     

肝移植术后早期肺部细菌感染的危险因素分析

目的 分析原位肝移植术后早期肺部细菌感染的发生情况及其危险因素。方法 回顾性分析笔者所在医院2010年1月至2012年6月期间行下腔静脉逆灌注法原位肝移植术的96例终末期肝病患者的临床资料。采用多因素非条件logistic回归分析探索肝移植术后早期肺部细菌感染的危险因素。结果 96例患者中有29例于肝移植术后早期发生肺部细菌感染,感染率为30.21%,其中感染G-需氧菌19例（65.52%）,感染G＋需氧菌10例（34.48%）。患者的术前终末期肝病模型评分（OR=2.165,P=0.001）、术中输血量（OR=1.952,P=0.003）、术后3 d血肌酐平均值（OR=1.913,P=0.001）、术后3 d液体负平衡时间（OR=0.196,P=0.023）及术后住院时间（OR=1.923,P=0.003）均与术后早期肺部细菌感染有关。结论 原位肝移植术后早期易发生肺部细菌感染。术前改善患者基础状况、术中控制输血量、术后控制输液量和住院时间及术后改善肾功能均可减少术后早期肺部细菌感染的发生。     

Late cytomegalovirus disease following liver transplantation

The widespread use of antiviral prophylaxis or preemptive therapy among orthotopic liver transplantation (OLT) recipients has reduced the occurrence of early cytomegalovirus (CMV) disease. Late disease is increasingly reported. Little is known about CMV disease occurring beyond the first year after transplantation. The aim of this study was to evaluate the occurrence of CMV disease two or more years after OLT and to determine its risk factors and clinical features. Eighty-one consecutive OLT recipients followed for 2 years or longer after transplantation were included in the study. Data were collected on demographic and clinical variables, clinical presentation, treatment, and outcome of late CMV disease. Late CMV disease occurred in 7/81 liver recipients (8.5%) at a mean time of 5.9 years after OLT (range: 3.5--9.3, median: 6.3 years). All seven patients were women, with a mean age of 47.7 years (range: 26--60, median: 59 years). There was no association between the development of late CMV disease and the occurrence of rejection episodes, treatment with corticosteroids, or the early use of antiviral prophylaxis. Clinical presentation included fever and disturbed liver functions in all patients, one patient had concurrent CMV pneumonitis and one CMV retinitis. Though all patients responded to ganciclovir, two had recurrent disease episodes and one patient died of secondary bacterial sepsis. Late-onset CMV disease can occur several years after OLT. Although it manifests classic clinical features of early disease, it is not associated with traditional risk factors and its pathogenesis may differ from that of early disease.     

Late cytomegalovirus disease following liver transplantation

The widespread use of antiviral prophylaxis or preemptive therapy among orthotopic liver transplantation (OLT) recipients has reduced the occurrence of early cytomegalovirus (CMV) disease. Late disease is increasingly reported. Little is known about CMV disease occurring beyond the first year after transplantation. The aim of this study was to evaluate the occurrence of CMV disease two or more years after OLT and to determine its risk factors and clinical features. Eighty-one consecutive OLT recipients followed for 2 years or longer after transplantation were included in the study. Data were collected on demographic and clinical variables, clinical presentation, treatment, and outcome of late CMV disease. Late CMV disease occurred in 7/81 liver recipients (8.5%) at a mean time of 5.9 years after OLT (range: 3.5--9.3, median: 6.3 years). All seven patients were women, with a mean age of 47.7 years (range: 26--60, median: 59 years). There was no association between the development of late CMV disease and the occurrence of rejection episodes, treatment with corticosteroids, or the early use of antiviral prophylaxis. Clinical presentation included fever and disturbed liver functions in all patients, one patient had concurrent CMV pneumonitis and one CMV retinitis. Though all patients responded to ganciclovir, two had recurrent disease episodes and one patient died of secondary bacterial sepsis. Late-onset CMV disease can occur several years after OLT. Although it manifests classic clinical features of early disease, it is not associated with traditional risk factors and its pathogenesis may differ from that of early disease.     

Incisional hernia after liver transplantation

BACKGROUND: Incisional hernia is a potential complication of orthotopic liver transplantation (OLT), with various options for repair. STUDY DESIGN: We conducted a retrospective review of a series of adult patients with incisional hernias after OLT to identify risk factors and to compare methods of repair. RESULTS: Incisional hernia repair was performed in 44 of 959 patients (4.6%) who underwent OLT from 1999 to 2005. Mean age at time of OLT was 53 years, and 73% were men. One or more complications of OLT occurred in 33 patients (75%) and included reoperation for bile leak or hemoperitoneum (34%), pulmonary problems (27%), early acute rejection (7%), and severe ascites and retransplantation (5% each). Incisional hernia was diagnosed at 419 days (range 62 to 1,524 days) and repaired at 471 days (range 109 to 1,581 days) after OLT. Presentation included pain or discomfort (78%) and incarceration or strangulation (5%); 17% were asymptomatic. Herniorrhaphy techniques included fascial repair with onlay polypropylene mesh reinforcement (n=25, 57%); fascial repair only (n=15, 34%); or inlay mesh sewn to fascial edges (n=4, 9%). Complications of repair included recurrence in seven patients (16%) and wound infection and seroma in one patient each. Recurrence occurred in five patients with primary repair and two with mesh techniques (33% versus 6%, p=0.04). CONCLUSIONS: Incisional hernia is a late complication of OLT for which male gender and early post-OLT complications are risk factors. Repair is safe when undertaken after acute problems have resolved and is best accomplished using mesh reinforcement of autologous tissue.     

Colonization with methicillin-resistant Staphylococcus aureus after liver transplantation.

Methicillin-resistant Staphylococcus aureus (MRSA) is a frequent cause of infection after orthotopic liver transplantation (OLT). Colonization with MRSA is associated with a higher risk of infection. Previous studies have shown a high prevalence of MRSA colonization among OLT candidates. However, the risk of colonization with MRSA after OLT is still unclear. The objective of this study was to estimate the incidence and the factors associated with colonization with MRSA after OLT. This was a prospective cohort study including patients submitted to OLT between the years 2000 and 2002. Surveillance cultures of nasal swab specimens were performed within the 1st 72 hours of hospital admission and, subsequently, on weeks 2, 6, 13, and 26. Patients whose baseline cultures revealed nasal carriage of MRSA were excluded. A total of 60 patients were included in the study. The median follow-up was 72 days. A total of 9 patients (15%) became colonized. In multiple logistic regression analyses, the use of a urinary catheter for > or =5 days (P = .006), postoperative bleeding at the surgical site (P = .009), and preoperative use of fluoroquinolones (P = .08) were associated with a higher risk of colonization. Patients without any of these risk factors did not become colonized. In conclusion, nasal carriage of MRSA is frequently acquired after OLT. Periodic postoperative screening for MRSA carriage should be an integral component in programs designed to reduce nosocomial MRSA transmission in these patients. Further studies are needed to set up and validate a predictive model that could allow targeting postoperative screening to high-risk OLT recipients.     

Low Prevalence of Colonization with Vancomycin-Resistant Enterococcus in Patients Awaiting Liver Transplantation

The orthotopic liver transplant (OLT) population has been particularly affected by the increase in vancomycin-resistant enterococcus (VRE) infections in recent years. Pre-transplant colonization prevalence, the role of spontaneous bacterial peritonitis (SBP) antimicrobial prophylaxis as a risk factor, and the risk of post-OLT infection in colonized patients are all unknowns. We prospectively evaluated OLT candidates at our center with the aim of answering these questions. Vancomycin-resistant enterococcus colonization status was determined by rectal culture. Data collected included illness severity, antibiotic use (including SBP prophylaxis), waiting time, previous hospitalizations, and invasive procedures. Eighty-eight patients (31 female, 57 male, median age 52 years) were enrolled. The most common diagnoses were hepatitis C (49%), primary sclerosing cholangitis (13.6%), and alcoholic liver disease. Median MELD score was 11.5 (range 7-24), and median waiting time was 551 days (range 1-2224). Vancomycin-resistant enterococcus risk factors were common in our patients: recent hospitalization in 16%, recent antibiotic exposure in 39%, and renal insufficiency in 7%. Seventeen percent were receiving SBP prophylaxis. Despite the presence of established risk factors, VRE colonization prevalence was 3.4%. Preliminary limited data showed poor correlation between screening rectal cultures and operative/peri-operative cultures. Vancomycin-resistant enterococcus colonization prevalence in an OLT candidate population with mid-level MELD scores was low, and SBP prophylaxis was not a significant risk factor.     

Cumulative risk of cardiovascular events after orthotopic liver transplantation

As survival after orthotopic liver transplantation (OLT) improves, cardiovascular (CV) disease has emerged as the leading cause of non-graft-related deaths. The aims of our study were to determine the cumulative risk of CV events after OLT and to analyze predictive risk factors for those experiencing a CV event after OLT. We identified all adult patients who underwent OLT at our institution for end-stage liver disease between October 1996 and July 2008. The cumulative risk of CV events after OLT was analyzed with the Kaplan-Meier method. Multivariate logistic regression analysis was used to identify factors independently associated with CV events after OLT. In all, 775 patients were included in our study cohort (mean age of 53.3 years, female proportion = 44%, Caucasian proportion = 84%, median follow-up = 40 months). The most common indications for OLT were hepatitis C virus (33.2%), alcohol (14.5%), and cryptogenic cirrhosis (12.7%). Eighty-three patients suffered 1 or more CV events after OLT. Posttransplant metabolic syndrome was more prevalent in patients with CV events versus patients with no CV events (61.4% versus 34.1%, P < 0.001). According to a multivariate analysis, independent predictors of CV events were an older age at transplantation [odds ratio (OR) = 1.2, addition of 95% confidence interval (CI) = 1.1-1.3, P = 0.006], male sex (OR = 2.0, 95% CI = 1.2-3.3, P = 0.01), posttransplant diabetes (OR = 2.0, 95% CI = 1.3-3.3, P = 0.003), posttransplant hypertension (OR = 1.8, 95% CI = 1.1-3.0, P = 0.02), and mycophenolate mofetil (OR = 2.0, 95% CI = 1.3-3.2, P = 0.003). Among post-OLT patients, the cumulative risk at 5 years of 13.5%, respectively. In conclusion, cardiac complications after liver transplantation are common (Approximately 10% of patients experience 1 or move cv events). Patients with posttransplant hypertension and diabetes, which are modifiable risk factors, are approximately twice as likely to experience a CV event.     

肝移植术后新发恶性肿瘤四例临床分析

目的 探讨肝移植术后新发恶性肿瘤的临床特征、危险因素和防治措施.方法 回顾性分析2003年8月至2008年12月间行肝移植术的726例受者中新发恶性肿瘤的临床资料.结果 在726例肝移植受者中,术后新发恶性肿瘤4例,发生率为0.6%;患者均为男性;新发恶性肿瘤的类型分别为:急性髓性白血病、胃癌、肺癌和未分化肝肉瘤;患者肝移植时年龄为42～57岁,中位年龄52岁,肿瘤确诊时的年龄为45～60岁,中位年龄53岁;从接受肝移植手术至发生肿瘤的时间为6～38个月,中位时间31个月.4例患者均死于肿瘤进展和多器官功能衰竭.肝移植术至死亡时间为12～48个月,中位时间39.5个月;确诊为新发恶性肿瘤至死亡时间为6～10个月,中位时间8.5个月.结论 肝移植术后新发恶性肿瘤国内发病率低于国外;确诊时间较晚是患者死亡的主要原因;重视癌前病变和高危因素,早期诊断,早期治疗是提高疗效的关键.     

肝移植术后新发恶性肿瘤四例临床分析

目的 探讨肝移植术后新发恶性肿瘤的临床特征、危险因素和防治措施.方法 回顾性分析2003年8月至2008年12月间行肝移植术的726例受者中新发恶性肿瘤的临床资料.结果 在726例肝移植受者中,术后新发恶性肿瘤4例,发生率为0.6%;患者均为男性;新发恶性肿瘤的类型分别为:急性髓性白血病、胃癌、肺癌和未分化肝肉瘤;患者肝移植时年龄为42～57岁,中位年龄52岁,肿瘤确诊时的年龄为45～60岁,中位年龄53岁;从接受肝移植手术至发生肿瘤的时间为6～38个月,中位时间31个月.4例患者均死于肿瘤进展和多器官功能衰竭.肝移植术至死亡时间为12～48个月,中位时间39.5个月;确诊为新发恶性肿瘤至死亡时间为6～10个月,中位时间8.5个月.结论 肝移植术后新发恶性肿瘤国内发病率低于国外;确诊时间较晚是患者死亡的主要原因;重视癌前病变和高危因素,早期诊断,早期治疗是提高疗效的关键.