肝脏再移植原因及效果分析

目的探讨再次肝移植的原因及效果，并比较不同供肝来源与再移植的关系。 方法回顾性分析2000年1月至2018年5月四川大学华西医院1 429例肝移植受者临床资料。首次肝移植供肝来源分别为尸体供肝686例、心脏死亡器官捐献(DCD)供肝346例和活体供肝397例。其中31例受者接受再次肝移植(32例次，其中1例受者接受2次再移植)，再移植率为2.24%(32/1 429)，供肝来源分别为尸体供肝23例、DCD供肝6例、活体供3例。再移植间隔时间中位数为311 d(88～845 d)，间隔1～7 d 3例，8～30 d 1例，31～365 d 15例，>1年13例。采用Kaplan-Meier法计算肝脏再移植术后受者生存时间并绘制生存曲线，采用Breslow法比较再移植间隔时间>1年及≤1年的受者1、5和10年生存率，采用Fisher确切概率法比较不同供肝来源的受者再移植率。P<0.05为差异有统计学意义。 结果截至2018年5月，31例肝脏再移植受者术后12例存活(38.7%)、19例死亡(61.3%)，中位生存时间为17个月(2～102个月)。尸体供肝、DCD供肝和活体供肝再移植率分别为3.4%(23/686)、1.7%(6/346)和0.8%(3/367)。尸体供肝再移植率高于活体肝移植，差异有统计学意义(P＝0.007)，DCD供肝再移植率与尸体供肝、活体供肝再移植率相比，差别均无统计学意义(P＝0.137和0.222)。其中18例再移植间隔时间<1年的受者，6例存活、12例死亡；13例再移植间隔时间≥1年的受者，6例存活、7例死亡。31例肝脏再移植受者术后1、5和10年生存率分别为64.2%、51.2%和46.6%。再移植间隔时间<1年的受者1、3和5年生存率分别为49.4%、41.2%和30.9%，间隔时间≥1年的受者1、3和5年生存率分别为84.6%、65.8%和65.8%，二者差异无统计学意义(χ²＝2.946，P>0.05)。 结论再移植是肝移植术后移植物失功的唯一有效治疗方法，再移植术后受者往往病情危重，围手术期死亡率高，胆道并发症及排斥反应是再次肝移植的主要原因。应该慎重把握再移植手术时机，目前亟待更多的研究对再移植做进一步探讨。

The causes and outcomes analysis of liver re-transplantation

ObjectiveTo analyze the causes and outcomes of liver re-transplantation and compare the relationship between different sources of donor liver and re-transplantation. MethodsThe clinical data of 1 429 liver transplantation recipients underwent liver transplantation between January 2000 and May 2018 in West China Hospital of Sichuan University were retrospectively analyzed. For the first liver transplantation, 686 cases of donor livers were from cadaveric donors, 346 cases were from donation after cardiac death (DCD) and 397 cases were from living donors. Thirty-one recipients received re-transplantation (32 cases, one received two times) and the rate of re-transplantation was 2.24% (32/1 429), among which 23 cases of donor livers were from cadaveric donors, 6 cases of donor livers were from DCD and 3 cases of donor livers were from living donors. The median interval time of re-transplantation was 311 d (88-845 d). Three recipients recieved re-transplantation from 1 to 7 days after the first transplantation, 1 recipients recieved re-transplantation from 8 to 30 days after the first transplantation, 15 recipients recieved re-transplantation from 31 to 365 days after the first transplantation and 13 recipients recieved re-transplantation 1 year later after the first transplantation. The Kaplan-Meier method was used to caculate the survival time of liver re-transplantation recipients and draw the survival curve. The suvival rate of 1-, 5- and 10-year of long time interval group (n=13, 1 year later after the first transplantation) and short time interval group (n=18, within 1 year after the first transplantation) were compared by the Breslow test. Fisher′s exact test was used to compare the re-transplantation rates of different sources of donor liver. ResultsTwelve recipients survived (38.7%) and 19 recipients died (61.3%) until May 2018. The median survival time was 17 months (2-102 months). The re-transplantation rates of cadaveric liver donor, DCD liver donor and living liver donor were 3.4% (23/686), 1.7% (6/346) and 0.8% (3/367), respectively. There was a significant difference in the re-transplantation rate between cadaveric donor liver and living donor liver (P=0.007), and there was no significant difference between DCD liver transplantation and other 2 types (cadaveric and living donor liver transplantation) (P=0.137 and 0.222). Among the 18 recipients in short time interval group, 6 recipients survived and 12 recipients died; for the left 13 liver re-transplantation recipients in long time interval group, 6 recipients survived and 7 recipients died. The 1-, 5- and 10-year overall survival rates of liver re-transplantation recipients were 64.2%, 51.2% and 46.6%. The 1-, 3-, 5-year overall survival rates of short time interval group and long time interval group were 49.4%/84.6%, 41.2%/65.8%, 30.9%/65.8%, respectively, which had no significant difference (χ²=2.946, P>0.05). ConclusionsRe-transplantation is the only effective treatment for graft dysfunction after liver transplantation. The liver re-transplantation recipients are often in critical condition with high perioperative mortality after transplantation. Biliary complications and rejection are the main causes of re-transplantation. We should carefully grasp the timing of re-transplantation, and more studies are urgently needed.