肝胰肾联合移植的免疫抑制治疗

Immunosuppressive therapy after simultaneous liver-pancreas-kidney transplantation

目的介绍1例存活超过1年的肝胰肾联合移植患者术后免疫抑制治疗方法。方法对1例肝炎后肝硬化合并尿毒症、Ⅰ型糖尿病、慢性胰腺炎患者施行原位背驮式肝、胰液空肠引流式胰、十二指肠及肾一期联合移植,采用二剂巴利昔单抗(舒莱)诱导,抗胸腺细胞球蛋白(ATG)、他克莫司(FK506)、吗替麦考酚酯(MMF)、泼尼松四联维持治疗。结果术后移植肝脏及胰腺功能1周内逐渐恢复;肾功能延迟恢复,于术后第16天因消化道大出血致肾脏血流下降,切除移植肾脏,于原移植部位进行第2次肾移植,术后第3天肾功能恢复正常,未发生排斥反应。患者已健康存活超过1年,移植肝、胰、肾功能良好,生活自理。结论肝胰肾联合移植术前后采用二剂舒莱诱导,同时用ATG、FK506、MMF及泼尼松作为免疫维持治疗安全有效,用药期间进行移植物功能、血药浓度及T细胞亚群(CD4+,CD8+)监测是防治排斥反应、感染及药物中毒的有效手段。

Objective To evaluate the immunosuppressive therapy after simultaneous liver-pancreas-kidney transplantation （SLPKT） in one case. Methods The simultaneous piggyback orthotopic liver and heterotopic pancreas duodenum and kidney transplantation was performed in a male patient aged 43 years who had cirrhosis accompanied by severe ascites secondary to type-B hepatitis, kidney failure and insulin-dependent diabetes mellitus and chronic pancreatitis （CP）. The pancreatic allograft exocrine secretion was drained to the proximal jejunum via a side-to-side duodenojejunostomy （without Roux-en-Y anastomosis）. lmmunosuppressive regimen consisted of simulect （for induction therapy） plus prednisone, tacrolimus （FK506） , mycophenolate mofeil （MMF） and anti-thymocyte globulin （ATG）. Intravenous simulect 20 mg was administered on the day of surgery and 4 d later. Results Normal liver and pancreas allograft function recovered within 7 d after operation, while delayed graft function （DGF） of the renal allograft occurred. The renal allograft was removed on the 16th d after operation due to breakdown of the renal allograft blood flow; then the second renal transplantation at the same position was performed. The second renal allograft obtained good function soon. Up to now, the patient has survived more than 12 months; no allograft rejection episode was found and no severe complications such as pancreatitis, thrombosis and severe infection occurred. Conclusions Before and after SLPKT, the use of simulect as induction therapy and use of ATG, FK506, MMF and prednisone as immunosuppressive maintenance therapy are safe and effective. Monitoring of allografts function, FK506 blood trough levels and T cell subgroup （ CD4^＋ , CD4^＋） is important for preventing rejection, severe infection and drug-related nephrotoxicity.