肝胰肾一期联合移植一例8年随访分析  

Simultaneous transplantation of liver , pancreas-duodenum and kidney： A 8-year follow-up and re-view

作　　者：张更[1] 王禾[3] 秦荣良[1] 秦卫军[1] 武国军[1] 杨晓剑[1] 于磊[1] 于铭[2] 康福霞[1] 吴东娟[1] 袁建林[1] 

机构地区：[1]第四军医大学西京医院泌尿外科,西安710032 [2]第四军医大学西京医院超声诊断科,西安710032 [3]第四军医大学唐都医院泌尿外科

出　　处：《中华泌尿外科杂志》2013年第12期937-941,共5页Chinese Journal of Urology

摘　　要：目的分析1例肝炎后肝硬化并发尿毒症伴胰岛素依赖型糖尿病患者行肝、胰、十二指肠、肾一期联合移植后的随访结果和临床特点。方法患者男性，43岁。进行性消瘦并尿量减少2个月，于2004年11月20日人院。实验室检查：丙氨酸转氨酶（ALT）117U／L，天冬氨酸转氨酶（AsT）1l3U／L，白蛋白（ALB）26．9g／L，总胆红素（TBIL）102μmol／L，尿素氮（BUN）23．6mmol／L，血肌酐（CRE）664μmol／L，乙肝系列示小三阳，空腹血糖10．8mmol／L，餐后血糖18．4mmol／L。B超及CT检查示肝硬化，大量腹水，脾肿大，胰腺头部大，主胰管扩张，双肾萎缩；肾动态显像检查示双肾功能严重损害，近似无功能。诊断为肝炎后肝硬化并发尿毒症伴胰岛素依赖型糖尿病。2005年1月17日在全麻下行肝、胰、十二指肠及肾一期联合移植术，术中采用原位背驮式方法进行肝移植，移植胰腺的外分泌采用空肠内引流，移植肾脏置于左髂窝。应用巴昔利单抗进行免疫诱导，兔抗人胸腺细胞免疫球蛋白治疗急性排斥反应。出院后长期规律随访。结果术后1周复查ALT57U／L，AST43U／L，ALB36．9g／L，TBIL22μmol／L，BUN26．5mmol／L，CRE683μmol／L，完全停用胰岛素，连续性肾脏替代治疗维持内环境稳定。术后第16天因急性排斥反应切除移植肾脏，于原移植部位进行第2次肾移植，术后第3天复查BUN6．5mmol／L，CRE155μmol／L。至今随访8年，免疫抑制方案为他克莫司＋醋酸泼尼松（5mg）的二联方案，他克莫司谷浓度维持3．0～4．5斗g／L，长期口服拉米夫定，0．1g，1次／d。移植肝、胰、肾功能均正常，乙肝病毒DNA定量〈1000U／ml，一般情况良好。结论原位背驮式肝移植及胰液空肠引流的胰一十二指肠及肾一期联合移植的技术安全，个体化用药及规律随访是患者获得长期存活的重要因素。Objective To investigate the long-term effect of triple organ transplantation （liver, kid- ney, and pancreas） in a patient with end-stage liver disease secondary to chronic hepatitis B and cirrhosis combined with chronic renal failure and insulin-dependent diabetes, and explore the optimal surgical proce- dure. Methods A 43-year-old male patient presented with progressive ematiation and hypouroerinia for 2 months. Blood test showed ALT 117 U/L, AST 113 U/L, ALB 26.9 g/L, TBIL 102 μmol/L, BUN 23.6 mmol/L, CRE 664 μmol/L. The fasting and postprandial plasma glucose were 10.8 mmol/L and 18.4 mmol/L, respectively. Ultrasound and CT scan showed hepatic cirrhosis, hydroperitoneum, splenomegaly, enlarged caput pancreatic duct, expanded main pancreatic duct and renal atrophy. Nephorgram showed both kidneys were impaired severely. The eaminations indicated exoerine pancreatic insufficiency and insulin-de- pendent diabetes related to chronic pancreatitis （CP） after develoDin~ end-sta^e hepatic and renal failuro.Simultaneous piggyback orthotopic liver and heterotopic pancreas-duodenum and renal transplantation was performed on 17-01-2005. Pancreatic exocrine secretions were drained enterically to the jejunum and the do- nor kidney was placed in left iliac fossa. Patient was prescribed prednisone, tacrolimus, mycophenolate mof- etil, ATG （Rabbit Anti-human Thymocyte Immunoglobulin） and simulect for immunosuppression. Results Satisfied hepatic and pancreatic function was achieved within 7 days after surgery. The kidney did not func- tion and CRRT （ Continuous Renal Replacement Therapy） was used. Subsequently, the donor kidney was re- moved at day 16 after surgery due to acute rejection. The second renal transplantation at the same position was perfromed and the new graft kidney functioned 3 days later. The patient had no rejection reaction or other complications such as pancreatitis, thrombosis, or local infections during the following 8 years. The patient has become insulin independent with normal liver and

关 键 词：肝 胰 肾 联合移植 糖尿病 

分 类 号：R656[医药卫生—外科学] R699[医药卫生—临床医学]