肝肾联合移植的临床经验

目的 探讨肝肾联合移植的适应证、手术技术、治疗经验及并发症防治。方法2001年10月至2005年3月进行肝肾联合移植13例。男12例，女1例。年龄41—66岁，平均54岁。原发病：多囊肝、多囊肾并尿毒症3例，酒精性肝硬化合并尿毒症2例，乙型肝炎肝硬化合并尿毒症7例，肾移植术后14年丙型肝炎肝硬化导致肝衰竭伴移植肾功能不全尿毒症1例。肝移植采用经典非转流原位肝移植术式和背驮式肝移植术式，肾移植为常规术式。病肝切除时注意细致分离第三肝门、创面及时止血。以抗胸腺细胞球蛋白或白细胞介素-2受体单克隆抗体作为免疫诱导，术后服用他克莫司、吗替麦考酚酯及激素维持免疫抑制治疗。患者门诊随访，复查血、尿常规．肝肾功能，他克莫司血药浓度以及移植物B超等。随访时间12—53个月。结果13例手术均成功。术后发生急性排斥反应1例，继发性出血1例，心肌梗死1例（死亡），胸腔积液4例，肺部感染3例（1例死亡）。除死亡病例外，所有并发症经相应治疗后逆转治愈。11例存活者肝肾功能正常，其中存活4年5个月者1例，存活3年以上者2例，2年以上者6例，1年以上者2例。1例49岁患者术后18个月死于心肌梗死，1例52岁患者术后13个月死于肺部巨细胞病毒感染。结论 肝肾联合移植是肝肾功能衰竭的有效治疗手段。娴熟的手术技巧和并发症的及时诊治是肝肾联合移植成功的关键。

Experience with combined liver-kidney transplantation

Objective To evaluate the indications, surgical techniques, clinical experiences and treatment of complications of combined liver-kidney transplantation (CLKT). Methods Overall, 13 patients (12 men and 1 woman) aged 41 - 66 years with a mean of 54 years underwent CLKT from October 2001 to March 2005. The primary diseases included polycystic liver and kidney with uremia in 3 cases, alcoholic cirrhosis with uremia in 2, liver cirrhosis caused by hepatitis B with uremia in 7, liver failure due to hepatitis C, cirrhosis and renal graft failure 14 years after renal transplantation in 1. Liver transplantation was performed with piggyback style or standard techniques without veno-venous bypass. Kidney transplantation followed conventional surgery. Care was taken of the third hepatic portal separation during hepatectomy. Immunosuppressive therapy included ATG or basiliximab as induction and tacrolimus/mycophenolate mofeil/ steroid as maintenance. Follow-up was 1 year to 4 years and 5 months. The blood, urine routines, liver and kidney function, blood concentration of tacrolimus, and B-ultrasound of the grafts were examined. Results The operation was successful in all 13 cases. Complications included acute rejection in 1 case, secondary hemorrhage in 1, myocardial infarction in 1 ( died) , hydrothorax in 4, and pulmonary infection in 3 (1 died) . Except death of 2 cases, the compilations were cured after treatment. Of 13 cases, 11 have been alive till now with good liver and kidney function. Of the 11 cases, 1 has survived 4 years and 5 months; 2, over 3 years; 6, over 2 years; 2, over 1 year. One died of myocardial infarction 18 months after transplantation. The other died of lung cytomegalovirus (CMV) infection at 13 months. Conclusions CLKT is effective for the treatment of liver and renal failure. Proficient surgical skill and immediate management of complications are crucial for successful CLKT.