临床肝肾移植三例体会

目的　探讨肝肾序贯移植和同期联合移植的手术难点及围手术期处理要点。方法　对2例肾移植术后发生药物性肝损害的病例实施肝移植 ,并对 1例巨大多囊肝、多囊肾的病例实施肝肾联合移植。结果　 2例肾移植术后实施肝移植的病例 ,其中 1例因术后肾功能衰竭导致多器官功能衰竭死亡 ;另 1例术后肝、肾功能良好 ,现已存活 1年。肝肾联合移植病例术中采用肝后腔静脉直接阻断法 ,使重达 10kg的巨大病肝得以顺利切除 ,并采用腔静脉成型术完成改良背驮式肝移植。术后免疫方案采用人源化单克隆抗体达利珠单抗免疫诱导下的以FK5 0 6、霉酚酸酯 (MMF)和激素的三联用药 ,肝、肾功能恢复良好 ,现为术后 6个月。结论　序贯性肝肾移植在术前应该准确评估移植肾功能 ,如果移植肾功能不良 ,应果断选择实施肝肾联合移植。肝后下腔静脉直接阻断法在实施巨大病肝切除时具有较大优势。肝肾联合移植术中及术后建议采用达利珠单抗免疫诱导下的免疫三联用药。

Preliminary study of serial and combined liver-kidney transplantation

Objective To study the operative difficulty and perioperative critical management in serial and combined liver-kidney transplantation.Methods Two cases with drug related hepatic injury after renal transplant received liver transplantation.One case of polycystic liver and kidney disease(PCLKD)was subjected to combined liver-kidney transplantation.The operative procedure and perioperative treatment experience for these cases were summarized.Results Of the 2 cases undergoing liver transplantation after renal transplantation,1 case died of postoperative renal failure and one has survived for 1 year and had normal hepatic and renal function.The case of combined liver-kidney transplantation was subjected to post-hepatic inferior vena cava direct blockage during operation.This method made enormous liver smooth resection, and improved piggy back liver transplantation with suprahepatic venacavaplasty.Postoperative immunosuppressive therapy included Zenapax-induced FK506,cellcept and prednisone.The patient has already survived for 6 months with normal hepatic and renal function.Conclusion Serial liver-kidney transplantation should accurately evaluate transplanted renal function before operation.Combined liver-kidney transplantation should be done if transplanted renal has poor function. The method of direct blockage post-hepatic inferior vena cava has advantage when enormous liver needs to cut.Immunosuppressive regime is recommended to adopt Zenapax-induced FK506,MMF and prednisone.