器官移植

2014 Vol. 5, No. 2

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Clinical Researches
Experimental Researches
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Editorials

2014, 5(2): 63-65. doi: 10.3969/j.issn.1674-7445.2014.02.001

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2014, 5(2): 66-67. doi: 10.3969/j.issn.1674-7445.2014.02.002

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Clinical Researches

System evaluation of hand-assisted laparoscopic and open living donor nephrectomy

Li Tao, Fu Shengjun, Dong Zhilong, Wang Zhiping, Wang Juan, Yang Li

2014, 5(2): 68-73. doi: 10.3969/j.issn.1674-7445.2014.02.003

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Objective To evaluate the safety and effectiveness of hand-assisted laparoscopic donor nephrectomy (HLDN) and open donor nephrectomy (ODN) systematically. Methods Literatures of randomized controlled trials (RCT) about HLDN and ODN were searched in Pubmed, Sciverse, Cochrone Library, China National Knowledge Infrastructure(CNKI), China Scientific Journal Database(VIP), China Biology Medicine(CBM), and Wangfang Database through internet. According to the inclusion and exclusion criteria, 2 reviewers screened the literatures independently, and Meta-analysis was conducted by software RevMan 5.2. Results A total of 10 RCTs including 1 230 patients were eligible after screening.Compared with ODN, the Meta-analysis revealed that HLDN possessed significantly longer operation duration and warm ischemia time [pooled odds ratio(OR)=35.81,95% confidence interval(CI):13.98-57.65, P=0.001; pooled OR=43.99, 95%CI: 32.31-55.66, P<0.00001), but less intraoperative blood loss(pooled OR=-78.90, 95% CI: -123.59--34.22, P=0.0005), lower incidence of complications (pooled OR=0.58, 95%CI: 0.39-0.86, P=0.006), and shorter hospital length of stay ［weight mean difference (WMD)=-1.15, 95%CI:-1.40--0.90, P<0.00001]. There was no significant difference in the time of taking normal diet between two groups(WMD=-0.11, 95%CI:-0.67 --0.45, P=0.70). Conclusions Compared with ODN, HLDN can improve the safety of operation and reduce the difficulty of operation. It is worthy of clinical promotion and application.

Clinical study of triple anti-tumor therapy for preventing tumor recurrence of terminal primary liver cancer after liver transplantation

Du Guosheng, Zhou Lin, Shi Bingyi, Zhu Zhidong, Song Jiyong

2014, 5(2): 74-78. doi: 10.3969/j.issn.1674-7445.2014.02.004

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Objective To investigate initially the availability and safety of combined application of sirolimus, thymosin α-1(Tα-1) and Huaier granule in preventing tumor recurrence of terminal primary liver cancer(TPLC) after liver transplantation(LT). Methods Combination group included 12 patients with TPLC who underwent LT in the 309^th hospital of Chinese People's Liberation Army from 2010 to 2012(all conform to Hangzhou standard). And historical control group included 15 patients with TPLC underwent LT at the same hospital from 2002 to 2006, whose follow up data was true and precise. During 1 month after LT, the type or dose of immunosuppressors was adjusted according to the individual differences of patients. Tacrolimus(FK506) and mycophenolate mofetil(MMF) were given to patients at first, and FK506 was gradually withdrawn and insteaded by sirolimus at 1 month after LT. Methylprednisolone of 500 mg was given during operation. Then small dose of methylprednisolone was given after operation and withdrawn at 1 week after LT. At the same time Tα-1 and Huaier Granule were added. The Tα-1 was injected for 10 days(1.6 mg per time, once a day), and after that injected twice a week. Huaier granule was given 20 g per time and three times a day. All the patients had been followed up. All the data including serum alpha-fetoprotein(AFP) changes, occurrence of allograft rejection, recurrence and treatment, survival time were collected accurately. Results In the combination group, the 12 cases were followed up for 8-35 months with the median follow up time of 18 months without loss or drop-out. All patients were survived. In the historical control group, the medium follow up time was 14 months till all the patients died. In the combination group, 2 cases developed isolated pulmonary metastasis after LT and 2 cases deveoped multiple pulmonary metastasis. All of the four cases were cured with the treatment of γ-knife. In history control group, 7 cases developed recurrence in 6 months after LT and all of the 15 cases developed recurrence in 1 year after LT. All of the 15 cases developed pulmonary metastasis(6 cases were isolated and 9 cases were multiple). All cases died of multi-section of tumor metastasis. Conclusions Combined application of sirolimus, Tα-1 and Huaier granule have significantly effect on preventing tumor recurrence of TPLC after LT, delaying tumor recurrence and prolonging survival time of patients.

Application of contrast-enhanced ultrasound in diagnosis of hepatic artery thrombosis after liver transplantation

Lu Qiang, Zhong Xiaofei, Ling Wenwu, Ma Lin, Luo Yan

2014, 5(2): 79-84. doi: 10.3969/j.issn.1674-7445.2014.02.005

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Objective To assess the value of contrast-enhanced ultrasound (CEUS) in the diagnosis of hepatic artery thrombosis (HAT) after liver transplantation. Methods From January 2004 to August 2012, 810 patients who underwent liver transplantation in Liver Transplantation Center of West China Hospital of Sichuan University were enrolled in this study. All the recipients received Doppler ultrasound scanning after operation. CEUS examination was performed in 58 patients with suspected HAT. Based on the gold standards of hepatic artery angiography, surgical outcome and clinical follow-up, the sensitivity, specificity, accuracy, positive predictive value and negative predictive value of CEUS in diagnosing HAT were calculated. Results Sixteen cases were diagnosed with HAT by CEUS, in which 15 were confirmed, one was misdiagnosed and no case was missed. The sensitivity, specificity, accuracy, positive predictive value and negative predictive value of CEUS in diagnosing HAT were 1.0, 0.977, 0.983, 0.938 and 1.0 respectively. The incidence and mortality of HAT were 1.9%, 53% respectively in the study. Conclusions When suspected with HAT by Doppler ultrasound after liver transplantation, patients should immediately receive CEUS. Patients with unobstructed hepatic artery diagnosed by CEUS can avoid receiving hepatic artery angiography.

Application of ultrasonography in evaluating biliary complications after living donor liver transplantation

Liao Mei, Ren Jie, Zheng Rongqin, Lyu Yan

2014, 5(2): 85-88,127. doi: 10.3969/j.issn.1674-7445.2014.02.006

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Objective To investigate the clinical application of ultrasonography in the diagnosis of biliary complications after living donor liver transplantation(LDLT). Methods Ultrasonography was used in 21 cases after right liver LDLT.The ultrasound images of transplanted liver and biliary tract were observed and compared with the result of percutaneous transhepatic cholangiography and drainage (PTCD). Results Biliary complications were identified in 7 of the 21 cases by PTCD and clinical follow up. Anastomotic stricture was detected in 5 cases, bile leakage in 1 case, and bile sludge in 1 case. Five cases were accurately diagnosed by ultrasound, including 4 cases with anastomotic stricture and 1 case with bile sludge. Effusion surrounding liver was observed in the case with bile leakage by ultrasound. Moreover, the time when anastomotic stricture was diagnosed by ultrasound was earlier than that when jaundice appeared or serum bilirubin increased in 4 cases. Conclusions Ultrasonography is a method with convenience, non-invasion, strong repeatability and high accuracy in diagnosis of biliary complications at the early time after LDLT, which has important value of clinical application.

Analysis on curative effect of salvage liver transplantation on patients with recurrence after hepatocellular carcinoma resection

Chang Hulin, Xu Xinsen, Qu Kai, Tian Min, Zhang Xiaogang, Wang Bo, Liu Xuemin, Yu Liang, Liu Chang, Lyu Yi

2014, 5(2): 89-94. doi: 10.3969/j.issn.1674-7445.2014.02.007

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Objective To explore the clinical efficacy of salvage liver transplantation(SLT) for hepatocellular carcinoma recurrence after hepatocellular carcinoma resection. Methods Clinical data of 68 patients who underwent liver transplantation treating for hepatocellular carcinoma from April 2005 to December 2012 in the First Affiliated Hospital of Xi'an Jiaotong University were analyzed retrospectively. Among them, 60 patients underwent primary liver transplantation(PLT, PLT group), and 8 patients underwent SLT for recurrence (SLT group). Intraoperative situation was compared between two groups including operation time, time of anhepatic phase, volume of blood loss and blood transfusion. Time in intensive care unit(ICU) and total length of hospital stay were compared between two groups. The occurrence of postoperative complication was compared between two groups. And the survival curves were drawn by the Kaplan-Meier method according to the follow-up result between two groups. Cumulative survival rate and tumor free survival rate were compared by log-rank tests between two groups. Results The operation time, anhepatic time, volume of blood loss and blood transfusion of patients in SLT group were higher than those in PLT group(all in P<0.05). There was no significant difference in the time in ICU and total length of hospital stay between two groups(all in P>0.05). There was no significant difference in the occurrence of bleeding, infection, acute rejection, renal failure and biliary complication between two groups(all in P>0.05). All the patients were followed up for 1-90 months with the average of 33 months. The cumulative survival rates of 1, 2 and 3 years were 87.5%, 75.0%, 62.5% in SLT group and 80.0%, 73.8%, 67.8% in PLT group respectively, and there was no significant difference by Kaplan-Meier analysis between two groups(P>0.05). And the tumor free survival rates of 1, 2 and 3 years were 75.0%, 62.5%, 50.0% in SLT group and 81.2%、68.6%、64.6% in PLT group, and there was no significant difference by Kaplan-Meier analysis between two groups either(P>0.05). Conclusions SLT has a good curative effect on the treatment of hepatocellular carcinoma recurrence after hepatocellular carcinoma resection. In the era of organ shortage,SLT is a effective treatment strategy.

Research on therapeutic strategies for urinary fistula after renal transplantation: a report of 72 cases

Hong Xin, Li Zhouli, Wang Shuang, Bi Jianlong, Cai Ming

2014, 5(2): 95-99. doi: 10.3969/j.issn.1674-7445.2014.02.008

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Objective To investigate the therapeutic strategies for urinary fistula after renal transplantation. Methods Among the 1 228 patients who received allogenic renal transplantation in Institute of Organ Transplantation, the 309^th Hospital of Chinese People's Liberation Army from June 2008 to December 2012, clinical data of 72 patients with urinary fistula after renal transplantation were analyzed retrospectively. Results The incidence of urinary fistula in this group was 5.86%. After the patients were diagnosed, the ureteral stents were kept indwelled firstly by the way of keeping Foley catheter. Common catheter or Latex tube were placed in the original wound or drainage outlet for drainage when the above therapy was ineffective. Surgical treatment was performed at last and tension-free anastomosis was taken. Among the 72 patients with urinary fistula, 46 cases were cured by conservative treatment. And 26 cases received surgical treatment after failed conservative treatment, in which 12 cases received repairment of fistula and placement of Foley catheter in the bladder, 10 cases were cured after receiving ureter-bladder anastomosis+ureteral stent placement, and 4 cases were cured by receiving autologous ureter-transplant kidney ureter anastomosis after failure of ureter-bladder muscle flap anastomosis. Two cases suffered from partial wound infection and were cured after enhancing drainage and anti-infective therapy. Conclusions Prevention is prior to treatment for urinary fistula after renal transplantation. The key to successful treatment is early diagnosis and proper choice of therapy. Once the diagnosis is confirmed, conservative treatment is given preferentially, then surgical treatment is taken when the conservative treatment is failed. The principle of tension-free anastomosis should be followed.

Analysis of acute rejection caused by immunosuppressants self-withdrawal after liver transplantation in three cases

Li Tao, Shen Chuan, Xie Junjie, Zhu Zhecheng, Shen Baiyong, Peng Chenghong

2014, 5(2): 100-102,122. doi: 10.3969/j.issn.1674-7445.2014.02.009

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Objective To investigate the clinical features and treatment in patients with acute rejection (AR) caused by immunosuppressants self-withdrawal (IS) after liver transplantation(LT). Methods Clinical data of 3 cases with AR due to IS after LT from January 2004 to June 2013 in Liver Transplantation Center of Ruijin Hospital Affiliated to Medical College of Shanghai Jiaotong University were analyzed retrospectively. Results Three patients were hospitalized for abnormal liver function after IS. The time of IS was 18-42 d. And acute cellular rejection was confirmed by liver biopsy histopathology. Immunosuppressants were reused and small dose of hormone was used after therapy of adrenocortical hormone shock or rabbit anti-human thymocyte immunoglobulin. Two patients recovered after treatment, and 1 patient died after invalid rescue. Conclusions IS after liver transplantation is prone to AR, usually resulting in serious consequences. Publicity and education of patients should be strengthened to improve their compliance of taking medicine. Once AR occurs, immunosuppressive drugs should be reused immediately with hormone shock or antibody therapy simultaneously.

Cognition in human organ transplantation: comparative study between medical and non-medical college students in Beijing

Liu Jia, Ouyang Yanan, Wu Chao, Zhang Yuting, Liu Qingming, Hong Baolin

2014, 5(2): 103-106. doi: 10.3969/j.issn.1674-7445.2014.02.010

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Objective To learn about the level of cognition in human organ transplantation and willingness of donation in medical and non-medical college students in Beijing and to investigate the differences of cognition in organ transplantation between these two kinds of college students. Methods A questionnaire survey was conducted by non-probability sampling in 960 students from 4 medical colleges and 4 non-medical colleges in Beijing. The contents of survey included 3 aspects: level of cognition in organ transplantation, views of advertising organ transplantation in colleges and personal willingness of organ donation. Results The effective return-ratio is 91.9%(882/960). Ninty-seven point three persent(858/882) of students knew about organ transplantation and 93.9% (828/882) regarded it was a career of benefiting mankind. There was significant difference in the approach of organ transplantation knowledge except media communication (χ²=11.20, P<0.05). Seventy-five point two percent (306/407) of medical college students thought it was necessary to advertise organ transplantation, while only 58.1%(275/473)of non-medical college students thought it was necessary, where significant difference was observed (χ²=28.33,P<0.01). The willingness of organ donation in medical college students was significantly higher than that in non-medical college students (χ²=6.054,P<0.05). Conclusions Both the medical and non-medical college students in Beijing have good knowledge and understanding on organ transplantation, but there are obvious differences in popularity degree of advertising and willingness of donation between these two kinds of college students.

Experimental Researches

Effects of hepatocellular carcinoma-associated fibroblasts on differentiation of monocyte-derived dendritic cells

Cheng Jintao, Zhang Yingcai, Deng Yinan, Lu Huiqiong, Zhang Qi, Yang Yang

2014, 5(2): 107-112. doi: 10.3969/j.issn.1674-7445.2014.02.011

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Objective To study the effects of hepatocellular carcinoma-associated fibroblasts(hCAF) on the differentiation of monocyte(Mo)-derived dendritic cell(DC). Methods The human hCAF were obtained from hepatic carcinoma tissue by enzyme digestion method. The healthy human peripheral blood mononuclear cells(PBMC) were prepared by density gradient centrifugation and CD14⁺Mo from healthy human peripheral white blood cells were purified by density gradient centrifugation and magnetic bead separation. hCAF-CD14⁺Mo(1:10) and CD14⁺Mo were treated by granulocyte-macrophage colony-stimulation factor(GM-CSF) (20 ng/ml) and interleukin(IL)-4 (20 ng/ml) which were added in day 1 and day 4 for 6 days. And then the cells of two groups were divided into two halves: one with or without the further stimulation of lipopolysaccharides(LPS, 200 ng/ml) for 3 days respectively. Finally the cells were divided into 4 groups: hCAF-Mo, hCAF-Mo+LPS, immature DC(iDC) and mature DC(mDC) group. Morphological changes of cells in 4 groups were observed by inverted fluorescence microscope. Cells in each group were divided into two parts. The expression of CD83,CD80, CD1a of cells in one part were detected by flow cytometry. And ability of T cells proliferation in the other part was analyzed by flow cytometry after co-culturing with CFSE-labeled T cells for 5 days. Results The result of inverted microscope showed that Mo couldn't differentiate into DC by the interference of hCAF. The expressions of CD83, CD1a and CD80 were (3.2±0.7)%,(61.7±8.4)%,(30.1±0.9)% respectively in iDC group,(80.2±2.8)%, (83.15±6.0)%,(96.1±1.9)% in mDC group,(1.6±0.9)%,(1.8±0.9)%,(16.0±3.2)% in hCAF-Mo group,(9.0±1.2)%、(1.1±0.4)%、(58.4±3.6)% in hCAF-Mo+LPS group. There was significant difference of the expressions of CD1a and CD80 between hCAF-Mo and iDC groups(both in P<0.01). Due to the extremely low expression of CD83 in iDC group, there was no significant difference between hCAF-Mo and iDC groups(P>0.05). There was significant difference of the expressions of CD83,CD1a and CD80 between hCAF-Mo+LPS and mDC groups (all in P<0.01). Proliferation rate of T cells were (3.3±0.9)% in iDC group, (34.5±7.3)% in mDC group,(5.3±1.2)% in hCAF-Mo group,(7.0±1.2)% in hCAF-Mo+LPS group. Compared with iDC group, mDC could promote the proliferation of T cells effectively. And the proliferation of T cells in hCAF-Mo and hCAF-Mo+LPS group was lower than that in mDC group(P<0.01). Conclusions hCAF can suppress the differentiation of Mo-derived DC, which may play an important role in immune escape of hepatocellular carcinoma.

Relationship between expression of inhibitor of growth 4 and recurrence/metastasis and prognosis of liver transplantation for hepatocellular carcinoma

Luo Laibang, Li Xinchang, Zhang Youfu, Xu Zhidan, Zhang Xiquan

2014, 5(2): 113-118. doi: 10.3969/j.issn.1674-7445.2014.02.012

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Objective To investigate the relationship between inhibitor of growth 4(ING4) expression and recurrence/metastasis and prognosis of liver transplantation for hepatocellular carcinoma(HCC). Methods Thirty HCC patients who underwent liver transplantation in the Liver Transplantation Center of Jiangxi Province People's Hospital from May 2003 to December 2007, were selected as objects. Tissue samples were acquired from HCC tissue and pericarcinomatous liver tissue(PCLT, 1 cm beside HCC tissue), which were resected by operation. Expression of ING4 protein in HCC tissue and PCLT was quantitatively measured by immunohistochemistry. Positive expression ratio and expression intensity of ING4 were compared between HCC tissue and PCLT. The expression level of ING4 in the tissues was detected by Western blot. According to the results of Western blot, ratio of ING4 expression between HCC tissue and PCLT was calculated. As ratio of 0.48 was boundary, 30 patients were divided into ING4 low expression group(n=15)and ING4 high expression group(n=15). Clinical pathological characteristics, recurrence/metastasis and prognosis of liver transplantation for hepatocellular carcinoma were analyzed between two groups. Results The immunohistochemistry result showed that the positive expression ratio of ING4 was respectively 63%(19/30)in HCC tissue and 93%(28/30)in PCLT, and there was significant difference(P<0.05). The strong positive expression ratio was 27%(8/30)in HCC tissue and 63%(19/30)in PCLT,and there was significant difference(P<0.05). The Western blot result showed that positive expression ratio of ING4 was 70%(21/30) in HCC and 97%(29/30)in PCLT,and there was significant difference(P<0.05). The expression level of ING4 protein in PCLT was higher than that in HCC tissue(197±31 vs. 109±24,P<0.05). In 30 pairs of samples, the ratio of ING4 protein down-regulation in HCC tissue was 83%(25/30). In clinical pathological characteristics, there were significant differences in number of tumor nodes(P=0.025), vein invasion(P=0.035), extrahepatic metastasis(P=0.017)and tumor cell differentiation(P=0.025) between ING4 low expression group and ING4 high expression group. Accumulative recurrence/metastasis rate of ING4 high expression group was lower than that of ING4 low expression group, and survival rate of ING4 high expression group was higher than that of ING4 low expression group(both in P<0.05). Median survival time of ING4 high expression group was longer than that of ING4 low expression group(720 d vs. 540 d, P<0.05). Conclusions The expression level of ING4 protein decreases in HCC tissue. The decrease is related with recurrence/metastasis after liver transplantation for HCC and affects the prognosis of patients.