15例肝肾联合移植报告
Combined liver and kidney transplantation:A report of 15 cases
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摘要: 目的 探讨肝肾联合移植(combined liver and kidney transplantation,CLKT)的手术时机,手术适应证及免疫抑制剂应用方案。 方法 对我院15例CLKT患者原发病的分析及肝肾功能评估,总结肝肾联合移植的患者手术适应证及手术时机,免疫抑制剂的剂量应用方案。 结果 15例全部存活,随访时间1.5-8(3.6±1.2)年。其中1例术后发生移植肾功能延迟恢复,经床旁RRT治疗2周后肾功能恢复。1例术前RRT 4周,术后2个月肾图显示原肾脏功能恢复。免疫抑制剂为他克莫司、霉酚酸酯及激素三联方案,肝肾联合移植应用激素和霉酚酸酯的时间与单肝脏移植相同,明显短于单肾脏移植,他克莫司在术后早期及术后6个月的用量与单肝脏移植患者相似,均明显低于肾脏移植患者(P<0.05和P<0.01),其排斥反应发生率与单肝脏移植和单肾脏移植比较无统计学差异。 结论 肝肾综合征患者术前RRT时间>6周,需施行肝肾联合移植;术前患肝功能衰竭并伴有原发肾脏疾病患者,如果蛋白尿>500mg/d、GFR<30ml/min或活检证实肾小球硬化>30%,需实施肝肾联合移植;肝肾联合移植患者免疫抑制剂的应用参考单纯肝脏移植方法即可达到满意疗效,激素和霉酚酸酯可在6个月停,他克莫司用量可低于单肾脏移植。Abstract: Objective To study the time,indications and use of immunosuppressant for combined liver and kidney transplantation(CLKT). Methods Indications,time and immunosuppressant dose for CLKT in 15 patients admitted to our hospital were analyzed and their liver and kidney functions were summarized. Results All the patients were survived and followed up for 1.5-8 years(mean 3.6±1.2 years).Renal failure occurred in 1 patient after CLKT and recovered 2 weeks after renal replacement therapy(RRT).Renogram showed that the original kidney function recovered 2 months after CLKT in 1 patient who received RRT for 4 weeks before operation.The patients were treated with combined immunosuppressants(tacrolimus,mycophenolate and hormone).The time to use hormone and mycophenolate in patients after CLKT was similar to that in those after liver transplantation.The dose of tacrolimus used in patients early and 6 months after CLKT was similar to that in those after liver transplantation,but significantly lower than that in those after renal transplantation(P<0.05).No significant difference was observed in rejection after liver or renal transplantation. Conclusion CLKT should be performed for patients with hepatic and renal syndrome(HRS) who received RRT for more than 6 weeks before operation and for those with liver failure accompanying primary renal disease with their proteinuria >500mg/d,GFR<30ml/min or glomerulosclerose >30% detected by biopsy.Immunosuppressant can achieve satisfactory outcomes in patients after CLKT.Mycophenolate and hormone should be withdrawn after 6 months.The dose of tacrolimus is smaller for patients after CLKT than for those after renal transplantation.