Objective To explore the application strategies of immunosuppression scheme after different types of liver transplantation for liver diseases. Methods According to the published literatures and the practical experiences in organ transplant center of Tianjin First Center Hospital,the immunosuppression schemes used after liver transplantation,the liver transplantation in patients with hepatitis C or liver cancer,patients after liver re-transplantation or with concurrent infection or with renal injury were summarized,and the spontaneous controllable tolerance (SOT) and the dosage reduction or elimination of immunosuppressor were approached. Results① Dose reduction and combined drugs therapy were the important strategies to adjust immunosuppressor after liver transplantation.②Maintaining low level immunosuppression,avoiding the repeat of cell rejection reaction and actively implementing antiviral therapy could slow down the progress of fibrosis after liver transplantation in HCV patients with recurrent hepatitis.③The induction therapy using anti CD25 monoclonal antibody and based on sirolimus(SRL) maintaining immune inhibition were the related factors to improve the survival rate of liver transplantation in patients with liver cancer. ④ We needed to strengthen the immune inhibitor concentration detection and timely adjust the dosage of calcineurin inhibitors(CNIs)or SRL after liver re-transplantation or when there was infectious complication. In severe cases with infection,we could consider to remove them.⑤We could reduce the progression of renal injury after transplantation by decreasing the CNIs or converting to SRL.⑥Inducing stable and durable immune tolerance and designedly withdrawing the immunosuppressor after liver transplantation in relatively stable patients,we might expect 20% patients achieving SOT. Conclusions The progress of immunosuppression scheme after liver transplantation on the one hand depends on the successive development of new types of immunosuppressor with lower adverse effect, and on the other hand,the more accurate genomics,pharmacogenetics and pharmacokinetic methods for monitoring the transplanted liver damage are necessary. We also need to look for specific immune monitoring methods to accurately assess the effectiveness and toxicity of immunosuppressive agents to gradually withdraw or stop the immunity inhibitors.

ObjectiveTo summarize 20 ABO-incompatible liver transplantation cases in our hospital and explore the treatment strategy. MethodsFrom January 2009 to July 2011,20 cases donorrecipient ABO blood type not-identical liver transplantation was performed at our hospital. 16 cases were ABO-incompatible(ABO-Ⅰ) and 4 were ABO-compatible(ABO-C ).The median follow-up was (13.3 ± 9.2) months.ResultsExcept preoperative MELD score,there were no significant difference in other perioperative data,the incidence of postoperative complications and the cumulative survival rate between ABO-C and ABO-Ⅰ group.There were 5 deaths in 20 cases,2 cases in ABO-C group and 3 cases in ABO-Ⅰ group,survival rate was 75％.The cause of death was perioperative multiple organ failure in 2 cases,liver cancer recurrence in 2 cases and cerebral hemorrhage in 1 case.There were 2 cases of acute rejection,3 cases of biliary complications and 3 cases of portal vein thrombosis developing postoperatively. Eleven patients had increased serum creatinine after operation,preoperative high creatinine existed in 6 cases and it maintained posttransplant high level for more than 7 days,the serum creatinine level in other 7 patients was back to normal level in 7 days.ConclusionsA combination splenectomy before the portal vein reperfusion,the protocol of basiliximab,tacrolimus (TAC)/mycophenolate mofetil (MMF)/steroids immunosuppression treatment,postoperative peripheral vascular dilatation treatment by Alprostadil,help achieve favorable outcome in selected patients who underwent ABO-incompatible liver transplant.

Objective To identify the changes of anti-HBs titers of patients with hepatitis B virus (HBV)-related diseases in the early stage (within the first week) post-liver transplantation (LT) and analyze their influencing factors.Method A total of 26 patients were enrolled in this study.They were all positive for HBsAg pre-LT and received the prophylaxis of lamivudine in combination with intravenous hepatitis B immunoglobulin (HBIG) in the first week post-LT.The titers of anti-HBs were detected daily in blood and drainage fluid every day in the first week post-LT.If the anti-HBs titers were greater than 1000 IU/L,blood and drainage were diluted,then detected again.Result The titers of anti-HBs in HBV-DNA negative groups,low HBsAg groups,and HBeAg negative groups were higher than those in the HBV-DNA positive groups,high HBsAg groups and HBeAg positive groups in the first five days post-LT.The median titer of anti-HBs in drainage fluid was 181.60 IU/L (0.00-968.50 IU/L).And the titer of anti-HBs in drainage fluid was correlated with anti-HBs titers in blood at the same time (r =0.927,P =0.000).The amount of anit-HBs calculated in drainage fluid was very high,but it fluctuated in a wide range (0.00-908.55 IU).Conclusion In the early stage post-LT,patients in high risk groups should receive higher doses of HBIG to maintain safe levels of anti-HBs,while the lower doses of HBIG are enough to the patients in low risk groups.Furthermore,the anti-HBs titers in blood aren't affected by the anti-HBs loss in drainage fluid.

Objective To evaluate the effect of aged cadaveric donor liver on long-term survival of liver transplant recipients.Methods Patients who underwent first time liver transplantation from cadaveric donor aging above 40 years were studied.Those patients were divided into donor age ＜ 50 group and age ≥ 50 group.Data for donor graft,recipient perioperative condition as well as long-term survival of recipients were compared between the two groups.Results There were 21 recipients receiving liver graft from a donor aging ≥ 50 (54.6-± 3.9) years.58 cases were given a liver graft from a donor aging ＜ 50 years (42.6 ± 2.9).The overall donor graft conditions were not different between the two groups (P ＞ 0.05).However,the median amount of operation time in donor age ≥50 group was longer than that in age ＜ 50 group (9.5 h vs.8.0 h,Z =-1.994,P =0.046).Median red blood cell (RBC) transfusion volume was greater in the age ≥50 group than that in age ＜50 group (1 000 ml vs.800 ml,Z =-2.593,P =0.010).During the follow-up,graft survival rates in 1,3 and 5 years were 74％,55％,55％ in donor age ≥50 group and 87％,66％,63％ in donor age ＜ 50 group,respectively (Z =0.903,P =0.342).Conclusions Use of aging cadaveric donor liver expandes donor pool,and is as well as safe,not hindering in graft's long term functions.

Objective To summary therapeutic method for delayed portal vein thrombosis after liver transplantation. Methods In 3100 cases undergoing cadaveric whole liver transplantation in a single center, there were 12 cases of delayed portal vein thrombosis after liver transplantation.Average occurring time was 29. 8 months after liver transplantation. Among these 12 patients, 2 cases were complicated with severe biliary complication (intrahepatic stricture) , 2 cases presented with liver failure of transplanted liver, and one case had portal vein compression by hepatic hilum tumor under the image examination, who received liver re-transplantation; two patients presented upper gastrointestinal bleeding, and they experienced endoscopic ligation and sclerotherapy respectively; the rest five patients without any clinical presentation were subjected to anticoagulation and antiplatelet therapy. Results Among 12 cases, 8 patients survived by the time of follow-up, including two patients undergoing re-transplantation; one patient lost follow-up. The liver function tests of the patients who survived were all normal. Conclusion The individualized therapeutic methods should be adopted for the patients with delayed portal vein thrombosis after liver transplantation.

ObjectiveTo investigate the effect of living donor right liver graft transplantation (LDLT) with middle hepatic vein (MHV) on the early congestion and regeneration of the donor remnant liver.MethodsBetween August 2008 and August 2009,28 LDLT were performed with 11 LDLT without MHV (group A) and 17 LDLT with MHV (group B).The donor operative time,intraoperative blood loss,postoperative hospital stay,bilirubin,INR,and ALT level were recorded in detail.We measured the volume of remnant liver by means of CT scan 2 weeks after operation and compare the degree of congestion and regeneration of the remnant liver between the two groups.ResultsThere were 10 cases in group B and 0 cases in group A suffering from congestion at segment Ⅳ,and the difference was significant(P =0.006).In group B,6 cases in type Ⅰ and 4 cases in type Ⅱ developed congestion at segment Ⅳ,and the difference was significant(P=0.035).Two weeks post operation,the volume of segment Ⅳ in group B was smaller than in group A(P=0.005).The regeneration rate of segment Ⅳ in group B was smaller than in group A (P =0.007),on the contrary,the regeneration rate of segment Ⅰ - Ⅲ in group B was larger than in group A( P =0.008 ).But the regeneration rate of remnant liver was the same in both groups (P =0.63 ).ConclusionsThe right lobe hemihepatectomy with MHV does not damage the early liver function of the donor significantly.The segment Ⅳ of the remnant liver suffered from congestion and impeded the regeneration,but was compensated by the regeneration of segments Ⅰ - Ⅲ.

Objective To summarize our experience of harvesting and using the organs of donors after cardiac death.MethodsForm March 2010 to October 2011,56 potential donors were diagnosed with cardiac death,who conformed to the classification of Maastricht Ⅲ criteria.There were 40 failure cases whose family refused to donate,and one failure case who suffered from serious infection.Finally,the success ratio of donation after cardiac death was 26.8％ (15/56).Twelve livers and 22 kidneys were transplanted into 12 and 20 recipients respectively.ResultsTwelve cases of liver transplantations had acceptable outcomes. The grafts of 4 cases out of 20 cases of kidney transplantations were removed after transplantation,and other recipients had acceptable outcomes.ConclusionCitizens organ donation after cardiac death can expand the number of suitable organs,but we need to strictly control the criteria for potential donors.

Objective To investigate the experience of treating Budd-Chiari syndrome through orthotopic liver transplantation.Methods The clinical data of LTx performed on 9 patients with Budd-Chiari syndrome from December 2003 to April 2010 were retrospectively analyzed. We summarize the preoperative image and surgical experience,and observe the occurrence of postoperative complications and survival. Results Budd-Chiari syndrome was diagnosed in 9 patients by the preoperative abdominal CT enhancement and vascular reconstruction,and cavity venography was done to observe obstruction and sub-type of CAVA vein.All 9 patients were subjected to cadaveric liver transplantation.Eight cases accepted classic non bypass type,and one accepted living related right lobe liver transplantation. Postoperative triple immunosuppressive regimen included tacrolimus,mycophenolate mofetil,and hormone.The average follow-up periods for all these 9 patients were 32.8 months (13 to 61 months). One patient died from the tumor recurrence at 35th month after the operation.Two patients received re-transplantation for the lost of the graft.One recipient received the donor liver with medium steatosis,and the re-transplantation was performed on the12th day after the first transplantation due to the primary non function of the graft.The other one received the secondary liver transplantation at 6th month after the first transplantation due to the biliary complication and died from the liver tumor recurrence. Among all the 9 cases,seizure disorder (1 case),dysfunction of duodenal papillary muscle (1 case) and small-for-size syndrome (one case) occurred after the operation.Pulmonary infection occurred in 4 cases:3 cases due to the bacterial infection and 1 due to the fungal infection. Neither outflow obstruction nor the recurrence of the Budd-Chiari syndrome occurred in this study.The 1- and 2-year survival rate after the operation was both 100％,and 3-year survival rate post-transplantation was 88.9％ (8/9).Conclusion Liver transplantation can be the ideal treatment to the Budd-Chiari syndrome based on the definite clinical diagnosis,accurate imaging evaluation and eligible modus operandi.

Objective To probe the correlation between preoperative pulmonary dysfunction and postoperative pulmonary complications in patients of orthotopic liver transplantation. Methods From August 2008 to June 2009, 71 orthotopic liver transplantation patients were studied. Preoperative pulmonary function and its relationship with postoperative pulmonary complications were analyzed.Results Preoperatively 65 out of 71 patients had abnormal lung functions, suffering from pulmonary diffusing capacity reduction (65 cases, 91.5% ), followed by reduction of restrictive ventilation function (30 cases, 42. 2% ), small airway function reduction ( 28 cases, 39.4% ), and obstructive ventilatory function reduction (21 cases, 29. 6% ). The incidence of postoperative pulmonary complications was 56. 3% including: pulmonary atelectasis, pneumonia, acute respiratory failure. The incidence of posttransplantation pulmonary complications in patients with pulmonary restrictive or obstructive ventilation function reduction was higher than in normal group (x2 = 6.703, P= 0.010; x2 = 4.768, P = 0.029), and there was significant difference in pulmonary complication rate between groups of moderate and severe diffusing capacity reduction and mild reduction and normal range (x2 = 8.478, P = 0.004 ).Conclusions Preoperative pulmonary function abnormality in patients before liver transplantation such as pulmonary ventilatory function reduction (VCmax ＜ 80% or FEV1.0 ＜ 80% ) and moderate to severe pulmonary diffusing capacity reduction (TLCOSB ＜ 60% ) predicts higher incidence of postoperative pulmonary complications.

Objective To summarize the experience of reconstruction of Ⅴ and Ⅷ hepatic veins in right lobe (without middle hepatic vein) living donor liver transplantation. Methods The clinical data of 55 cases of living donor liver transplantation of right lobe without middle hepatic vein were analyzed, and Ⅴ and Ⅷ hepatic veins were reconstructed. All donors underwent evaluation on the basis of vascular anatomy, GRWR and graft volume/ESLV. Fifty-one grafts underwent reconstruction of Ⅴ and Ⅷ hepatic veins with cold-storage cadaveric iliac veins. Great saphenous vein, varicose umbilical veins, recipient intrahepatic portal veins and recipient intrahepatic veins were used respectively in the remaining 4 cases. Results One recipient died of obstruction of out-flow on the postoperative day 43. One recipient was converted to cadaver donor liver transplantation at the 7th day after operation, because of acute liver function failure. The remaining 53 cases recovered successfully. Conclusion Reconstruction of Ⅴ and Ⅷ hepatic veins with proper materials in right lobe (without middle hepatic vein) living donor liver transplantation is feasible, and the effect is satisfactory.