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 GVHD 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 methylprednisone 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 immunosuppressant, symptomatic treatment, supplementation of nutrition, prevention of combined infections, and maintenance of immune function may be the optimal treatment of GVHD.

Objective To explore the evidences of the humoral factor involved in the liver allograft rejection, and to explore better monitoring methods and therapy of the humoral liver rejection. Methods After the humoral liver rejection, liver puncture biopsies were performed. Immunohistochemical examinations of C4d, CD20+ B lymphocytes and CD138+ plasma cells were performed to judge whether humoral factor was involved in liver rejection. The dosage of tacrolimus was increased first when rejection was identified. The patients with severe liver function damage were treated with methyllprednisolone, and the steroid-insensitive cases were treated with antithymocyte globulins (ATG) and rapamycin. Results 25 biopsies were performed in 16 patients. Humoral rejection was diagnosed for 15 times in 10 patients, cellular rejection was diagnosed for 6 times in 4 patients, and the both kinds of rejection occurred in the last 2 patients. The effect of methylprednisolone was obviously lower in the humoral rejection cases (29.4%, 5/17) than that of the cellular rejection cases (7/8). Steroid-insensitive humoral rejections were diagnosed in 12 biopsies from 7 patients receiving liver transplantation. One patient was cured with ATG and 5 patients were cured with addition of rapamycin. The case whose blood type was AB receiving a liver transplant from the donor of O blood type died of liver function failure even after an extensive treatment. Conclusions Humoral immune factors maybe involved in some acute and chronic liver allograft rejection. ATG and rapamycin are more effective for the patients with humoral liver rejection.

Objective To summarize the incidence,clinical presentation,diagnosis and treatment strategy of Mycobacterium tuberculosis(TB)infection in liver transplanted recipients.Methods The data of clinical situation,laboratory examination,imaging,diagnosis and management of 3 patients who were infected TB after liver transplantation were retrospectively analyzed.Results The incidence of TB infection after liver transplantation was 1.2 %(3/246).One patient had was pulmonary tuberculosis complicated by pleural tuberculosis,one had pleural tuberculosis complicated with tuberculosis in liver.Both of them had recovered after standard antituberculosis therapy and no relapse up to now.One patient was found to have tuberculous cavity in the lung died of multiple bacterial and fungous infections postoperatively.As clinical presentations of the patients with TB infection were atypical after liver transplantation,it would take about 30d to confirm the final diagnoses after the onset of symptoms.The serologic examination for TB were all negative results in the 3 patients,and the only positive result was of purified protein derivatives(PPD)skin test in one patient.Administration of antituberculous drugs could decrease the plasmic level of immunodepressant,but the level could be kept normal by adjusting the dosage of immunodepressant.In neither of the 3 patients discontinuation of drugs was necessary because of hepatotoxicity of antituberculosis drugs.Anti-TB treatment was effective,safe and feasible.Conclusion The clinical presentation,diagnosis and treatment are specific for patients with TB infection after liver transplantation.Early diagnosis and rational treatment will lead to a better prognosis.

Objective To further probe and investigate the etiopathogenisis of acute lung injury(ALI)after in situ liver transplantation,and to search for an effective treatment.Methods ALI was final diagnosed as the oxygen saturation index(OSI)was less than 200.The arterial blood gas analysis and others clinical examinations were timely monitored to 189 of 211 patients undergone liver transplantation in situ.The other 22 cases died of other causes at the early stage after liver transplantation.The occurring of ALI was analyzed correlatively with protopathy.All the patients were given with the therapies of oxygen,antibiotics,immunosuppressant,drugs of liver protection,nutrition,diuretics,and vasodilators,and some criteria were measured continuously.The oxygen concentration and circulation volume were adjusted accordingly with blood gas analysis and central venous pressure respectively.Results ALI occurred within 146 of 189 patients(77.5%)at the early stage after liver transplantation in situ.All the cases were treated systemically and recovered to normal.The liver function kept unvaried during the period of treatment.By analyzing the patients' data,the occurrence of ALI showed a definite relation to the hepatic decompensation of patients' primary disease,the blood loss during operation,and to the liquid intake/output postoperation.Conclusion For the purpose of preventing or reducing the incidence of ALI,It is important to pay attention to the primary disease,keep stability of the blood dynamics of the patients during or after operation.Besides the oxygen therapy,systemic general treatment is also necessary for those patients who received in situ liver transplantation.

Hepatic myelopathy is a rare disease with high mortality. There has been no report of an effective treatment to date. In order to evaluate the beneficial effect of orthotopic liver transplantation in patient with hepatic myelopathy. One patient, who was suffering from hepatie myelopathy complicating hepatic pathology, underwent liver transplantation in 2002 was studied. The muscle strength of the patient’s extremities was carefully assessed both pre-operatively and postoperatively. It was found that symptoms and signs of hepatic myelopathy were improved, especially the muscle strength recovered from 1-2 degree to 3-4 degree half a year after the operation. Therefore it is our belief that liver transplantation might be beneficial to patients who are suffering from hepatic myelopathy as a complication of the hepatic disease.

Objective To evaluate the application of artificial liver support system (ALSS) in severe hepatitis patients before liver transplantation. Methods Double lumen catheters were inserted into the femoralvein to construct the blood conduit in patients receiving ALSS. The blood purification apparatus was applied for plasma replacement and blood perfusion with PIS separator and HA hemoperfusion apparatus. The plasma replacement capacity was 3000ml-4000ml (average 3200 ml) with albumin 20g. The average dosages of both heparin and protamine were 25 mg. The separation speed was 26 ml/min. The replacement blood flow was 100-150 ml/min, and the average treatment time was 120 min. Results The liver function markers, including TB, DB, ALT, AST and NH 3, were improved in patients with ALSS. Conclusion ALSS could correct the imbalance of homeostasis of the patients, eliminate the toxic substances effectively and provide valuable support for liver transplantation.

Objective To explore causative factors, and prevention and treatment of nonanastomotic biliary stricture (NABS) after orthotopic liver transplantation. Methods The donor’s liver together with celiac artery and its branches were havvested rapidly without injury to reduce heat ischemia time and artery loss, then the bilinary duct was flushed to clean out residual bile. During operation, when the portal vein was opened, the hepatic artery of the donor liver was flushed with heparin saline. Post-operatively, acute or chronic rejection and cytomegalovirus infection should be prevented. When NABS occurred, it was treated with bilinary balloon dilatation. Results Of 36 patients with liver transplantation, 4 patients (11.1%, 4/36) were found to suffer from NABS. Two patients were cured, in one patient it was improved after dilatation, and one patient died. Conclusion NABS is mainly related to artery loss, cold/warm ischemia injury, ischemia/reperfusion injury, bile toxicity injury, immune injury and cytomegalovirus infection etc. Biliary balloon dilatation is the major treatment for NABS. Retransplantation is necessary for some severe cases.

Objective To observe the therapeutic effects and side-effects of tacrolimus (FK506) in the recipients who had undergone liver transplantation, and summarize the clinical experience of its use. Method The clinical data of 36 recipients of allogeneic liver transplants followed by tacrolimus-based anticoagulant regimen were retrospectively analyzed. After liver transplantation, all the recipients received the triple-drug immunosuppressive protocol, including tacrolimus as the basic drug, mycophenolat-mofetil (MMF), and prednisone. Twenty-four of 36 cases received Zenapax as an antibody induction therapy. Results Acute rejection occurred in 3 of 36 cases. After the use of methylprednisolone and OKT3, acute rejection was reversed. The main side-effects of tacrolimus were nervous system disturbance(40.0%), hypertension(13.3%), hyperglycemia(26.7%), and liver dysfunction(6.7%). Conclusion Tacrolimus is a safe and potent immunosuppressive agent, which can decrease the incidence of rejection in liver transplant recipients. The dosage of tacrolimus should be adjusted according to trough level with in the therapeutic window. The timely and appropriate adjustment of the immunosuppressive strategy is essential for the recipient and graft survival. Meanwhile, it is emphasized that the regime should be individualized. [HS(1*2/3]

Objective To discuss and prevent hepatic artery thrombosis (HAT ) or stenosis (HAS) after orthotopic liver transplantation (OLT). Methods In harvesting the donor's liver, the hepatic artery should be obtained together with its origin from the celiac artery as a whole. Damage to the hepatic artery should be avoided during dissection, the endothelium should not be injured, especially that of its branches. When the portal veins of the donor and the recipient were opened, the matching arteries were anastomosed end to end. If the diameter of the anastomosing artery was less than 5 mm, a branching section of the artery was selected, the bifurcation septum was divided so that the arterial end was enlarged to ensure a good anastomosis. The endothelium of the artery should be kept intact during the procedure. Results In 36 patients with OLT, no patients suffered from HAT or HAS. Conclusion The important procedures to prevent HAT or HAS in OLT are harvest of a complete donor's arteries, suitable selection of hepatic artery for anastomosis, precise technique of vascular anastomosis, and appropriate use of anticoagulant.

Objective To explore a new therapeutic method to intractable rejection after liver transplantation.Methods Low dose prograft and rapamycin were given to 2 patients with intractable acute rejection and 2 patients with intractable chronic rejection confirmed by biopsy after liver transplantation, which had no response to normal treatment. The blood concentration of prograft was controlled in 3～5 ?g/L and rapamycin in 6～12 ?g/L. Rapamycin was withdrawn and prograft was increased to normal dose while the rejections were rectified.Results Four allograft rejections were all reversed in the end with this method. In the course of this therapy, one of the 4 patients had CMV pneumonia and cured with antiviral therapy. One had diabetes and another's diabetes got more critical. The blood glucose recovered to the primary level after the withdrawal of rapamycin.Conclusion The intractable acute and chronic rejection which has no response to normal treatment can be reversed by combined use of low dose prograft and rapamycin.