肝肾联合移植的适应证及时机

背景：肝肾联合移植以来，肾功能不全甚至肾功能衰竭已不再是肝脏移植的禁忌症。 目的：探寻肝肾联合移植适应证及移植时机，以利合理应用稀缺的实体器官供体。 方法：收集接受肝肾联合移植患者15例，回顾性分析其移植前状态与移植后移植肾及原肾恢复情况间的状态。 结果与结论：入组15例肝肾联合移植患者均手术顺利，至今存活，随访1.5-8(3.6±1.2)年。入组患者中出现移植肾功能延迟恢复1例，行床旁连续性肾脏替代治疗治疗2周后肾功能逐渐恢复；1例移植前行连续性肾脏替代治疗治疗 4周的肝肾综合征患者，移植后2个月行肾图检查提示原肾功能恢复正常；另2例移植前连续性肾脏替代治疗超过6周的肝肾综合征患者，移植后行肾图提示原肾功能未恢复；伴有原发肾病的终末期肝病患者移植前24 h尿蛋白> 500 mg、肾小球滤过率< 30 mL/min或经穿刺活检证实肾小球硬化率> 30%，肝肾联合移植后行肾图提示原肾逐渐失功。移植前行连续性肾脏替代治疗治疗超过6周的肝肾综合征患者，需施行肝肾联合移植；移植前伴有原发肾病的终末期肝病患者，如果24 h尿蛋白> 500 mg、肾小球滤过率< 30 mL/min或经活检证实肾小球硬化率> 30%，需施行肝肾联合移植。

Indications and timing for combined liver and kidney transplantation

BACKGROUND:Since the development of liver and kidney transplantation, renal insufficiency and renal failure are no longer contraindications for liver transplantation. OBJECTIVE:To explore the indications and timing for performing combined liver and kidney transplantation and to allocate the scarce organs rationally.  METHODS:The clinical data were reviewed in 15 patients with combined liver and kidney transplantation including the diagnosis of primary diseases and distinct hepatorenal function before operation, and the situations of transplanted kidneys and original kidneys were analyzed. RESULTS AND CONCLUSION:All patients were operated successfully and being alive now. The follow-up time was 1.5－8 years, and the mean time was (3.6±1.2) years. Among the 15 patients with combined liver and kidney transplantation, one patient had delayed renal function recovery, and then recovered after treated with continuous renal replacement therapy for 2 weeks; for one patient who had hepatorenal syndrome and was treated with continuous renal replacement therapy for 4 weeks prior to transplantation, the renogram examination at 2 months after renal transplantation showed the original kidney function was recovered; for another two patients who had hepatorenal syndrome and were treated with continuous renal replacement therapy for 6 weeks prior to transplantation, the renogram examination after transplantation showed the original kidney function was not recovered. For the patients who had end-stage liver disease and primary nephrotic syndrome, the urine protein > 500 mg, glomerular filtration rate < 30 mL/min or the puncture biopsy confirmed that the glomerulosclerosis rate > 30% before transplantation, the renogram examination after combined liver and kidney transplantation showed original renal dysfunction. The patients with hepatorenal syndrome who had been treated with continuous renal replacement therapy for more than 6 weeks before transplantation should be treated with combined liver and kidney transplantation. However, the patients with end-stage liver disease and primary nephrotic syndromethe should be treated with combined liver and kidney transplantation if the urine protein > 500 mg, glomerular filtration rate < 30 mL/min or the puncture biopsy confirmed that the glomerulosclerosis rate > 30%.