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 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.

Objective To study the prognosis of patients with end-stage liver cirrhosis who using controlled cardiac death liver donor in situ liver transplantation. Methods Seven cases of transplants which used liver donated after cardiac death were done in our center. The preoperative and postoperative data were analyzed. The prognosis of these patients was observed. Results Except one recipient died of upper gastrointestinal bleeding at the 9th day after surgery, the remaining 6 patients were followed up for more than 12 months (mean 15.7 months) and the prognosis was satisfactory.Conclusion Patients can get good prognosis after the liver transplants with donated liver after cardiac death which meets the Maastricht Classification type Ⅲ.

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 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 assess the clinical application of Cylex ImmuKnow assay in patients with renal dysfunction after liver transplantation for individualized immunosuppressive therapy.Method Twenty adult patients undergoing liver transplant between January 2009 and December 2011 received regular ImmuKnow assay monitoring combined with determination of serum tacrolimus trough concentration to guide immunosuppressive regimens,all of whom showed sustained renal dysfunction 6 months after transplant with normal and stable liver function.Clinical data were collected to observe the changes of renal function in those patients after treatment.Results The recipients were followedup for 15-54 months,received ImmuKnow assay 61 times and the results fluctuated 33-943 μg/L [median 282 μg/L,interquartile range (IQR) 267 μg/L].After ImmuKnow monitoring,serum creatinine level in patients was decreased significantly from median 151.8 μmol/L with IQR 44.9 μmol/L to median 114.9 μmol/L with IQR 35.3 μmol/L (Z =-3.845,P =0.000),and estimated glomerular filtration rate (eGFR) was increased significantly from median 0.746 mL/s with IQR 0.025 mL/s to median 1.005 mL/s with IQR 0.454 mL/s (Z =-3.771,P =0.000).ImmuKnow results showed a linear correlation with the white blood cell count in patients (Spearman correlation coefficient r =0.429,P =0.001),but no linear correlation with the patients' age,primary disease before transplantation,postoperative time,serum tacrolimus trough concentration,lymphocyte count,CD3+ T lymphocyte count,CD4+ T lymphocyte count or CD4+/CD8+ T lymphocyte ratio (P＞ 0.05).Conclusion Cylex IrmmuKnow assay can be applied in patients with renal dysfunction after liver transplantation for individualized immunosuppressive therapy monitoring,which is of certain clinical value.