肝肾联合移植的临床体会(附10例分析)

Combined liver-kidney transplantation:a retrospective analysis of 10 cases

目的总结肝肾联合移植的治疗体会。方法收集接受肝肾联合移植的10例患者的临床资料,对其手术时间、供肝和供肾热缺血时间、术中出血量、术后并发症,受者和移植物功能等情况进行总结分析。结果 10例患者的原发病分别为乙型病毒性肝炎（乙肝）后肝硬化5例,其中合并药物性肾衰竭1例、移植肾失功1例、肝肾综合征3例;原发性肝细胞癌合并肾衰竭2例;酒精性肝硬化合并尿毒症1例;先天性多囊肝和多囊肾（polycystic liver and kidney disease,PCLKD）1例;肝移植术后缺血性胆管狭窄并肾衰竭1例。肝移植采用改良背驮术式,肾移植采用常规移植方法,将移植肾置于左髂窝或右髂窝。手术均获成功,肝移植手术时间（444±175）min,肾移植手术时间（184±36）min;移植肝和移植肾热缺血时间为8min以内;术中出血量（3367±1726）ml。术前严重感染的5例,术后1周内死于多器官功能衰竭。存活的5例患者中,其中1例患者术后反复肺部感染,给予呼吸机辅助支持治疗、积极抗感染后治愈,其余4例患者无明显并发症。5例患者均存活,生存12~32个月,受者和移植物功能良好。结论肝肾联合移植是治疗终末期肝、肾功能同时受损的有效的不可替代的治疗手段。选择合适病例,把握适当的手术时机,术中控制手术时间、热缺血时间和出血量,术后积极处理并发症是获得良好疗效的关键。

Objective To investigate the results and influential factors of combined liver-kidney transplantation.Methods The clinical data of 10 cases undergone combined liver-kidney transplantation were collected and analyzed,including the operation time,the warm ischemia time of donator,the volume of blood loss during operation,postoperative complications and the graft function.Results The primary diseases of the 10 cases respectively included 5 cases with posthepatitic cirrhosis（1 case combined with drug renal failure,1 case combined with allograft dysfunction and 3 cases combined with hepatorenal syndrome）,2 cases with hepatocellular carcinoma combined with renal dysfunction,1 case with alcoholic cirrhosis combined with uremia,1 case with polycystic liver and kidney disease,and 1 case with ischemic biliary stricture post-transplantation combined with renal dysfunction.The modified piggyback technique was adopted in liver transplantation while general operation method was adopted in kidney transplantation by placing the transplanted kidney at the reci-pient＇s left or right iliac fossa.All operations were successfully performed.The operation time of liver transplantation and renal transplantation was（444±175）min and（184±36）min.The warm ischemia time of the transplanted liver and kidney was within 8 min.The volume of blood loss during the operation was（3 367±1 726）ml.Five cases with severe infection before transplantation died of multiple organ failure during the first week after operation.In the 5 survival cases,1 case developed recurrent lung infection and recovered after ventilator-assisted support and anti-infection therapy,while the other 4 cases had no obvious complications.All of 5 cases survived during follow-up from 12 to 32 months.The grafts function were well restored after operation.Conclusions Combined liver-kidney transplantation is the only effective treatment for patients with end-stage liver disease with renal dysfunction.Suitable case selection,perfect opportunity of operation,carefully control of operation time,warm ischemia time of donator and volume of blood loss and active managements after operation are very important for good prognosis in recipients.