再次肝移植80例临床报告

目的总结再次肝移植的临床经验。方法回顾性分析我中心自1999年1月至2005年7月实施的80例再次肝脏移植的原因、与首次肝移植的时间间隔、选择的术式、1年存活率、围手术期死亡率及死亡的主要病因。结果再次肝移植的主要原因是胆道并发症,占45．0％;距首次移植术后超过1个月再次移植围手术期死亡率（19．6％）明显低于首次移植术后8～30d行再次移植患者（70．0％）;围手术期死亡的主要原因是感染（54．5％）和多脏衰（18．2％）。结论选择合适的手术适应证及手术时间,根据术中情况决定具体术式,制定合理的免疫抑制方案及有效的抗感染治疗是提高再次移植生存率的关键。     

早期和晚期再次肝移植的临床分析

目的 比较首次肝移植术后因移植肝失功实施早期和晚期再次肝移植的疗效并总结临床经验.方法 回顾性分析2004年1月至2009年7月间接受再次肝移植手术的36例患者的临床资料,包括早期再次肝移植17例和晚期再次肝移植19例.早期和晚期再次肝移植患者的年龄分别为(45±13)岁和(48±10)岁,与首次肝移植的时间间隔分别为(49±54)d和(514±342)d.结果 胆道并发症是早期再次肝移植和晚期再次肝移植的主要适应证.其他常见的适应证包括早期再次肝移植的血管并发症和晚期再次肝移植的原发病复发.除了MELD评分外,两组再次肝移植术中出血量、冷缺血时间、手术时间和围手术期病死率的差异均无统计学意义.早期再次肝移植中有8例患者死亡,其中3例死于脓毒症相关性疾病,3例死于多器官功能衰竭;晚期再次肝移植中有10例患者死亡,其中4例死于脓毒症相关性疾病,3例死于肝癌的复发.早期和晚期再次肝移植的l、2年的生存率分别为52.9％、41.2％和63.2％、52.6％,差异无统计学意义(P＞0.05).结论 早期再次肝移植和晚期再次肝移植治疗移植肝失功的疗效相当.手术适应证及时机的正确把握、娴熟的手术技巧以及围手术期有效的抗感染治疗是提高再次肝移植患者总体存活率的关键.     

再次肝移植临床分析

目的总结再次肝移植的病因、预后及手术方式。方法回顾性分析天津市第一中心医院1999年1月至2005年12月实施的101例再次肝移植的病因、术前MELD评分、与首次肝移植的时间间隔、手术术式选择、1年生存率、围手术期死亡的主要原因。结果再次肝移植1年的生存率为71．6％;再次移植的主要原因是胆道并发症（45、5％）;MELD值≤20的病例1年生存率（83．8％）明显高于MELD值为20—30和〉30的病例（57．1％和66．7％）;首次移植术后超过1个月再次移植围手术期生存率（83．8％）明显高于首次移植术后8—30d接受再次移植患者（41．7％）;围手术期死亡的主要原因是感染（54．2％）。结论选择合适的手术时机,根据术中情况决定具体术式,积极有效的抗感染治疗是提高再次肝移植生存率的关键。     

再次肝移植治疗移植肝失功的经验分析

目的 总结再次肝移植治疗移植肝失功的临床经验。方法 回顾分析1993年4月至2005年4月期间施行的9例再次肝移植受者临床资料。再次肝移植的原因包括肝动脉血栓（2／9）,门静脉血栓（1／9）,胆道并发症（6／9）;9例再次肝移植均为尸肝移植,3例采用经典原位肝移植,6例采用背驮式肝移植,6例采用Roux-en-Y胆肠内引流,1例供受体门静脉间用供体脾静脉搭桥,1例供体肝动脉与供体腹主动脉之问用供体脾动脉搭桥。结果 全组无手术死亡,5例术后未出现并发症,1例术后门静脉吻合口狭窄,3例术后6个月内死亡。结论 首次肝移植后由于胆道和血管并发症导致移植肝失功是再次肝移植的主要适应证,不失时机地进行再次肝移植是治疗移植肝失功惟一有效的方法。     

儿童活体肝部分移植术进展

目的：介绍近年来儿童活体肝移植术的进展。方法：以全球活体肝部分移植中心京都大学的资料为重点，综述近年来全球儿童活体肝移值术的现状。结果：活体肝移植仍然是儿童患者的首选术式，其主要适应证是胆汁淤积性肝病（80％），全球最大一组资料（462例）表明，其1、3、5年累计生存率分别为79．8％、77．0％和77．0％，优于同期接受全肝移植的患者（129例，1、3、5年累计生存率分别为76．0％、70．0％和65．0％），且择期手术患者的生存率（85．0％）优于急诊手术者（67．0％）；死亡原因主要是排斥反应和感染。此外，对于儿童患者，还开展了原位辅助性活体肝部分移植和再次活体肝移植术。结论：严格选择手术适应证及手术时机和做好术后1年内的管理是提高远期疗效的关键，儿童活体肝部分移植术疗效明显优于成人，也优于全肝移植术。     

再次肝移植单中心16例分析

目的 研究再次肝移植术的手术适应证、临床效果和预后.方法 回顾性分析2004年4月至2013年4月我中心进行的612例肝移植临床资料.结果 共有16例再次肝移植,再次肝移植率2.61％(16/612).两次移植间隔时间(即首次移植物存活时间)为(16.2±18.3)个月(10 d至64个月,中位时间9.5个月).再次肝移植后总体病死率50％(8/16),围手术期病死率18.75％(3/16);再次移植物存活时间为(37.4±34.3)个月(3d至94个月,中位时间39.5个月);受者平均生存时间(53.6±33.9)个月(10 d至94个月,中位时间57个月),5年总体生存率48.3％.结论 对于肝移植术后常规方法难以治疗的严重并发症,再次肝移植是合理、必要和可行的救治手段.再次肝移植在首次移植6个月后进行,有利于降低再次肝移植的围手术期病死率.     

肝癌肝移植后肿瘤复发的原因与治疗

肝癌是否适宜肝移植治疗历来就有争论 ,但就肝细胞肝癌同时伴有肝硬化 ,肝功能较差的患者而言 ,肝移植似乎是惟一的既可以去除肝癌病变 ,又可以去除肝硬化 ,恢复肝功能的治疗方案。近年来随着肝癌肝移植病例的增加及术后随访时间的延长 ,人们意识到移植后肝癌的复发问题是导致患者远期生存率低的主要原因 ,因此认识肝癌复发原因 ,严格掌握肝移植适应证 ,明确肝癌复发的治疗方案是相当重要的。一、原因导致肝癌复发的原因有多种 ,主要包括肝癌肝移植适应证的选择 ,手术术式及手术操作 ,术后免疫抑制治疗等。1.肝癌肝移植适应证选择过宽 :从肿…     

肝移植术后再次手术分析：附14例报告

目的总结肝移植术后因外科并发症行再次手术治疗的经验。方法对近4年余治疗的200余例肝移植患者中14例17例次术后再次手术患者的临床资料进行回顾性分析。结果17例次再手术（包括再次肝移植1例）治疗肝移植术后外科并发症或其他合并症，手术成功率为100％。14例中1例因腹腔内出血于再次术后10d死于肾衰竭并发ARDS，1例因胸穿后血胸于再次术后20d死于严重的腹腔和肺部感染；1例因左肝内胆管结石伴胆道感染于再次术后33d死于多器官衰竭；1例因肿瘤复发转移于再次术后25d死亡；其余10例存活至今且肝功能良好，生存率71．4％（10／14）。结论准确把握肝移植术后外科并发症的再次手术时机，积极手术干预是提高肝移植成功率和移植后生存质量的关键。     

肝脏移植治疗肝细胞癌

1963年临床肝移植实施以来 ,肝细胞癌 (hep atocellularcarcinoma,HCC)一直是肝脏移植 (livertransplantation ,LT)的适应证之一。然而 ,其术后高复发率和低长期生存率问题一直困扰着临床医师。本文重点综述LT治疗HCC的围手术期相关处理问题。1　LT治疗HCC的受体选择　　上世纪     

再次肝移植6例报道及文献复习

目的 总结再次肝移植的临床经验.方法 对6例患者施行再次肝移植,再次肝移植的原因分别为原发性移植肝无功能(2例)、排斥反应(2例)、胆管吻合口狭窄(1例)以及原发性硬化性胆管炎(1例).供肝植入采用背驮式及经典原位肝移植术; 术后免疫抑制治疗采用他克莫司(tacrolimus)、吗替麦考酚酯(MMF)和激素三联免疫抑制方案.结果 5例治愈,已分别存活16个月、11个月、8个月、5个月及2个月,1例于术后第4 天死于多器官功能衰竭.术后并发症有深部真菌感染及切口感染.结论 再次肝移植是移植肝功能衰竭的有效治疗方法,适应证及手术时机的正确把握、围手术期的严密监测和正确处理是提高再次肝移植患者存活率的关键.     

单个移植中心连续4000例肝移植后长期生存情况回顾

目的：评价大样本肝移植病人长期生存情况和分析影响移植疗效的动静因素。背景回顾：自1983年以来肝移植被接受为治疗终末期肝病的主要选择之一，随着免疫抑制剂的发展，手术技术的不断完善，取肝及保存方法改进，生存期获不断延长。虽然报告影响近期生存因素的文章甚众，但分析影响长期生存因素者却不多见。方法：回顾性分析1981年2月至1998年4月连续施行的4000例肝移植资料（随访至2000年3月），并对移植时供，受体年龄，受体性别和诊断以及上份等因素进行比较；也统计了再移植率，再移植原因和死亡原因。结果：全组的总生存率为59％，统计18年生存率为48％；小儿，女性和1990年以后接受移植的病人生存情况产好。以FK506为基础的免疫抑制剂使因急，慢性排斥反应而施行的再移植率显著下降，手术一年后，移植肝脏丧失功能病人死亡的曲线相对趋于平稳，疾病复发，急性肿瘤和与年龄相关的并发症是移植物丧失功能的最主要因素。结论：随着年供的推移，病人和移植物的生存活情况获显著改善，由急性，慢性排斥反应所致的移植物失功已属十分罕见，与年龄相关和疾病相关的移植物失功，已构成肝移植患者长期生存的最大威胁。     

Long-term survival after liver transplantation in 4,000 consecutive patients at a single center

OBJECTIVE: To evaluate the long-term survival outcomes of a large cohort of liver transplant recipients and to identify static and changing factors that influenced these outcomes over time. SUMMARY BACKGROUND DATA: Liver transplantation has been accepted as a therapeutic option for patients with end-stage liver disease since 1983, with continual improvements in patient survival as a result of advances in immunosuppression and medical management, technical achievements, and improvements in procurement and preservation. Although many reports, including registry data, have delineated short-term factors that influence survival, few reports have examined factors that affect long-term survival after liver transplantation. METHODS: Four thousand consecutive patients who underwent liver transplantation between February 1981 and April 1998 were included in this analysis and were followed up to March 2000. The effect of donor and recipient age at the time of transplantation, recipient gender, diagnosis, and year of transplantation were compared. Rates of retransplantation, causes of retransplantation, and cause of death were also examined. RESULTS: The overall patient survival for the entire cohort was 59%; the actuarial 18-year survival was 48%. Patient survival was significantly better in children, in female recipients, and in patients who received transplants after 1990. The rates of retransplantation for acute or chronic rejection were significantly lower with tacrolimus-based immunosuppression. The risk of graft failure and death was relatively stable after the first year, with recurrence of disease, malignancies, and age-related complications being the major factors for loss. CONCLUSION: Significantly improved patient and graft survival has been observed over time, and graft loss from acute or chronic rejection has emerged as a rarity. Age-related and disease-related causes of graft loss represent the greatest threat to long-term survival.     

再次肝移植治疗移植肝失功能22例报告

目的 总结再次肝移植治疗移植肝失功能的临床经验。方法 回顾分析2004年1月至2006年6月期间中山大学附属第三医院施行22例再次肝移植受者的临床资料，结合文献加以讨论。再次肝移植的原因分别为移植术后胆道并发症（12例）、移植术后肝癌复发（4例）、肝动脉栓塞（2例）、肝动脉狭窄（2例）以及乙肝复发（2例）。再次移植率为3．62％，供肝植入均采用改良背驮式肝移植技术。结果 全组无手术死亡，8例随访至今分别存活21、14、8、3个月各1例，12、1个月各2例；14例存活2周到28个月不等。首次肝移植术后8～30d行再次肝移植病人围手术期病死率最高，为66．7％；1年内死亡10例，主要死亡原因为感染（60％）。结论 再次肝移植是移植肝失功能的惟一有效的治疗方法，正确掌握手术时机及适应证，钻研手术技巧，合理的个体化免疫抑制方案以及围手术期有效的抗感染治疗是提高再次肝移植病人存活率的关键。     

肝移植术后肝动脉并发症的再次肝移植治疗

目的 探讨再次肝移植治疗肝移植术后肝动脉并发症的可行性及手术时机.方法 回顾性分析2003年12月至2006年12月收治的13例肝动脉并发症患者再次肝移植的临床资料.结果 再次肝移植的无肝期、手术时间和首次移植比较差异无统计学意义(P=0.291,P=0.312),术中出血量、ICU停留时间和首次移植比较差异有统计学意义[(3.1±1.1)L比(1.5±0.9)L(P=0.005),(4.3±1.8)d比(3.2±2.5)d(P=0.015)].围手术期病死率为38.5%(5/13),其中移植间隔1个月内死亡1例(1/4),超过1个月死亡4例(4/9).死亡原因分别为急性肾功能衰竭2例、严重感染2例、心肌梗死1例.8例存活,随访6～51个月,中位生存时间22.5个月.结论 再次肝移植是治疗肝移植术后肝动脉并发症导致不可逆性肝功能损害时的惟一有效手段.选择适宜的手术时机和手术方式、调整免疫抑制方案、加强围手术期管理是提高再次肝移植疗效的关键.     

Recipient survival and graft survival are not diminished by simultaneous liver-kidney transplantation: an analysis of the united network for organ sharing database

Recipients of solitary liver and kidney transplants are living longer, and this increases their risk of long-term complications such as recurrent hepatitis C virus (HCV) and drug-induced nephrotoxicity. These complications may require retransplantation. Since the adoption of the Model for End-Stage Liver Disease, the number of simultaneous liver-kidney transplantation (SLK) procedures has increased. However, there are no standardized criteria for organ allocation to SLK candidates. The aims of this study were to retrospectively compare recipient and graft survival with liver transplantation alone (LTA), SLK, kidney after liver transplantation (KALT), and liver after kidney transplantation (LAKT) and to identify independent risk factors affecting recipient and graft survival. The United Network for Organ Sharing/Organ Procurement and Transplantation Network database (1988-2007) was queried for adult LTA (66,026), SLK (2327), KALT (1738), and LAKT procedures (242). After adjustments for potential confounding demographic and clinical variables, there was no difference in recipient mortality rates with LTA and SLK (P = 0.02). However, there was a 15% decreased risk of graft loss with SLK versus LTA (hazard ratio = 0.85, P < 0.001). The recipient and graft survival rates with SLK were higher than the rates with both KALT (P <0.001 and P <0.001) and LAKT (P = 0.003 and P < 0.001). The following were all identified as independent negative predictors of recipient mortality and graft loss: recipient age ≥ 65 years, male sex, black race, HCV/diabetes mellitus status, donor age ≥ 60 years, serum creatinine level ≥2.0 mg/dL, cold ischemia time > 12 hours, and warm ischemia time > 60 minutes. Although the recent increase in the number of SLK procedures performed each year has effectively decreased the number of potential donor kidneys available to patients with end-stage renal disease (ESRD) awaiting kidney transplantation, SLK in patients with end-stage liver disease and ESRD is justified because of the lower risk of graft loss with SLK versus LTA as well as the superior recipient and graft survival with SLK versus serial liver-kidney transplantation.     

再次肝移植的原因与预后分析

目的探讨再次肝移植的原因和预后。方法回顾性分析2003年11月26日至2012年5月26日期间笔者所在医院行再次肝移植215例患者的临床资料,分析其再次肝移植的原因与预后。结果笔者所在医院完成再次肝移植215例,其中行2次肝移植200例,3次肝移植14例,4次肝移植1例。第2次肝移植的主要原因为胆道并发症（53.5%,115/215）,其次为肝移植物原发性无功能或功能低下（8.4%,18/215）;第3次肝移植的原因主要为胆道并发症（5/14）,其次为肝癌复发（2/14）。早期（肝移植术后1个月内）与后期（肝移植术后1个月后）第2次肝移植移植物生存率比较差异有统计学意义（P=0.005）,后期第2次肝移植移植物生存率较高。第3次肝移植移植物生存率低于第2次肝移植（P=0.043）。与胆道并发症者比较,肝癌复发者（P=0.001）和肝移植物原发性无功能或功能低下者（P=0.033）移植物生存率较低,慢性移植肝失功能者移植物生存率较高（P=0.037）。结论胆道并发症为再次肝移植的最主要原因。移植后早期行再次肝移植的效果不佳,其主要原因是围手术期的死亡增加。因肝癌复发而行再次肝移植患者移植物的预后不理想,而慢性移植肝失功能患者移植物的预后最佳。     

The National Liver Transplantation audit: an overview of patients presenting for liver transplantation from 1994 to 1998. On behalf of the Steering Group of the UK Liver Transplantation Audit

BACKGROUND: The aim of this study was to describe current clinical practice in liver transplantation in the UK and Ireland, to provide overall 1-year graft and patient survival rates, and to study some preoperative risk factors. METHODS: All patients receiving a liver transplant in the UK or Ireland between 1 March 1994 and 30 September 1998 were included. Data were collected on patients at the time of transplantation, 3 months after grafting and annually thereafter until the patient's death. The main outcome measures were graft and patient survival at 1 year. RESULTS: A total of 3102 liver transplants were carried out, of which 87 per cent were first transplants. The mean age at first transplantation was 42 (range 0-76) years. The most common indications for transplantation were primary biliary cirrhosis, alcoholic cirrhosis and posthepatitis C cirrhosis, but variations existed between sexes and centres. Risk factors associated with lower graft and patient survival were the presence of acute disease, being transplanted from hospital, and the need for renal and/or ventilatory support before operation. CONCLUSION: Donor and recipient demographics are consistent with data held by the European Liver Transplant Registry, as are 1-year graft and patient survival rates. Variation across centres in factors such as the primary indication for liver transplantation, population demographics, the clinical status of each patient, incidence of retransplantation and other risk factors contributes to the problem of adjusting for case mix.     

Effect of donor age on survival of liver transplant recipients with hepatitis C virus infection

BACKGROUND: Chronic hepatitis C virus (HCV) infection is the most common indication for orthotopic liver transplantation (OLT) in the United States. Recent studies from selected centers have suggested that older donor age is associated with worse outcomes after transplantation for HCV. METHODS: We analyzed the United Network for Organ Sharing Liver Transplant Registry database from April 1987 to March 2003 to examine predictors of death or retransplantation in patients with HCV. Univariate models for each predictor were evaluated. Factors significant in the univariate model were used to develop a multivariable model. RESULTS: Of 6,956 patients meeting the inclusion/exclusion criteria, 1,527 (22.0%) died or received retransplants during the first year after transplant. Recipients with graft failure were older, had greater serum creatinine levels, and were more likely to require mechanical ventilation and hemodialysis before transplant. Donors of patients with graft failure were older and more likely to have diabetes mellitus. In the multivariable regression model, predictors of graft failure at 1 year were donor age, recipient age, recipient creatinine greater than 2 mg/dL, and the requirement for mechanical ventilation for the recipient. CONCLUSIONS: Both older donor age and older recipient age plus markers of severity of disease, including requirement for mechanical ventilation and renal insufficiency, are negatively associated with survival after liver transplantation. These factors should be considered when assessing OLT recipient and donor candidacy in patients with HCV.     

Long-term outcome of liver retransplantation in children

BACKGROUND: Retransplantation of the liver is the only means of prolonging survival in children whose initial graft has failed. Patient and graft survival rates after retransplantation in most series have been inferior to rates after first transplantation. PATIENTS AND METHODS: Of 450 pediatric liver transplantations performed between January 1990 and March 2001, 50 were first retransplantations, 9 were second retransplantations, and 1 was a third retransplantation. The overall retransplantation rate was 13.3% (median age at retransplantation 4 years and median weight 15 kg). The median post-retransplantation follow-up was 73 (range, 6-139) months. RESULTS: Kaplan-Meier patient survival rates for the group (n=50) were 71.7%, 64.7%, and 64.7% at 1, 3, and 5 years, respectively. Graft survival rates were 65.6%, 56.7%, and 56.7% at 1, 3, and 5 years, respectively. This is significantly worse than rates for children undergoing first liver transplantation. There were 17 deaths, of which 9 occurred in the first month. Biliary complications occurred in 5 (10%) patients and vascular complications in 6 (12%). Improved patient and graft survival rates were observed in the later phase of the program, although the difference was not significant. Higher preoperative serum creatinine (P=0.001) and serum bilirubin (P=0.02) levels were associated with a higher postoperative mortality. CONCLUSION: Results of retransplantation in children remain inferior to those after first transplantation. There is a trend toward improving results. Liver retransplantation makes an important contribution to overall survival in children.