肝移植术后移植物抗宿主病治疗的初步经验(附2例报道)

Preliminary experiences on the treatment graft versus host disease after liver transplantation

目的总结肝移植术后移植物抗宿主病(GVHD)诊治的临床经验。方法对2例肝移植术后GVHD患者的临床表现、诊断、治疗及效果进行总结分析,包括GVHD发病时间,临床症状出现的先后顺序,免疫抑制剂的用法及用量,确诊后的治疗措施等。结果2例患者分别于术后第19、20天出现不明原因高热、皮疹及胃肠道症状,继之出现全血细胞减少,肝功能无明显受损。例1患者经用大量激素、增大免疫抑制剂的剂量等治疗无效,于术后第34天死亡,死亡原因为混合感染及多器官功能衰竭。例2患者早期高度疑似GVHD,应用小剂量甲泼尼龙治疗后减少或停用免疫抑制剂,注射丙种球蛋白,鼻饲加强营养,早期应用抗细菌、真菌及抗病毒药物,患者痊愈,截至目前(术后11个月)仍健康存活。结论肝移植术后出现不明原因发热、皮疹、胃肠道症状应警惕GVHD的发生,停用或减少免疫抑制剂、恢复受体的免疫系统、加强营养、预防感染是治疗的关键。

Objective To summarize the clinical experiences of diagnosis and treatment of graft versus host disease （GVHD） in patients, who had undergone liver transplantation. Methods The clinical symptoms, diagnosis, treatment and clinical effect of 2 patients with GVI-ID were analyzed, including the time of occurrence of GVHD after operation, the sequence of clinical symptoms, the methods of administration and the dosage of immunosuppressant, as well as therapeutic measures when the disease was confirmed. Results Both patients developed unidentified high fever, skin rash and gastrointestinal syndromes on the 19th and 20th day, respectively, after orthotopic liver transplantation, and then pancytopenia occurred. There was no obvious signs of liver dysfunction during the period. One of the two patients died of mixed infection and multiple organ failure the 34th day after the transplantation with an increased dosage of glucocorticoid and immunosuppressant. The other patient was highly suspected of having GVHD at the early period and treated with small dose of meth ylprednisone and immunosuppressant, or completely withheld the immunosuppressant contingent on the condition of the patient. Gamma globulin was used for upholding the immunity, nasal feeding for energy supplementation, and antibiotics, fungicide and antivirotics were administered to the patient. This patient was cured and still alive and healthy. Conclusions Patients with unidentified high fever, skin rash and gastrointestinal symptoms after liver transplantation should be suspected to have GVHD. Decrease the dose or withhold immunosup pressant, symptomatic treatment, supplementation of nutrition, prevention of combined infections, and maintenance of immune function may be the optimal treatment of GVHD.