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日入院.实验室检查:丙氨酸转氨酶(ALT) 117 U/L,天冬氨酸转氨酶(AST) 113 U/L,白蛋白(ALB) 26.9 g/L,总胆红素(TBIL) 102 μmol/L,尿素氮(BUN) 23.6 mmol/L,血肌酐(CRE) 664 μmol/L,乙肝系列示小三阳,空腹血糖10.8 mmol/L,餐后血糖18.4 mmol/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ALT 57 U/L,AST43 U/L,ALB 36.9 g/L,TBIL 22 μmol/L,BUN 26.5 mmol/L,CRE 683.μmol/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BUN 6.5 mmol/L,CRE 155 μmol/L.至今随访8年,免疫抑制方案为他克莫司+醋酸泼尼松(5 mg)的二联方案,他克莫司谷浓度维持3.0 ～ 4.5 μg/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＜1000 U/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-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.
目的 分析1例肝炎後肝硬化併髮尿毒癥伴胰島素依賴型糖尿病患者行肝、胰、十二指腸、腎一期聯閤移植後的隨訪結果和臨床特點. 方法 患者男性,43歲.進行性消瘦併尿量減少2箇月,于2004年11月20日入院.實驗室檢查:丙氨痠轉氨酶(ALT) 117 U/L,天鼕氨痠轉氨酶(AST) 113 U/L,白蛋白(ALB) 26.9 g/L,總膽紅素(TBIL) 102 μmol/L,尿素氮(BUN) 23.6 mmol/L,血肌酐(CRE) 664 μmol/L,乙肝繫列示小三暘,空腹血糖10.8 mmol/L,餐後血糖18.4 mmol/L.B超及CT檢查示肝硬化,大量腹水,脾腫大,胰腺頭部大,主胰管擴張,雙腎萎縮;腎動態顯像檢查示雙腎功能嚴重損害,近似無功能.診斷為肝炎後肝硬化併髮尿毒癥伴胰島素依賴型糖尿病.2005年1月17日在全痳下行肝、胰、十二指腸及腎一期聯閤移植術,術中採用原位揹馱式方法進行肝移植,移植胰腺的外分泌採用空腸內引流,移植腎髒置于左髂窩.應用巴昔利單抗進行免疫誘導,兔抗人胸腺細胞免疫毬蛋白治療急性排斥反應.齣院後長期規律隨訪. 結果 術後1週複查ALT 57 U/L,AST43 U/L,ALB 36.9 g/L,TBIL 22 μmol/L,BUN 26.5 mmol/L,CRE 683.μmol/L,完全停用胰島素,連續性腎髒替代治療維持內環境穩定.術後第16天因急性排斥反應切除移植腎髒,于原移植部位進行第2次腎移植,術後第3天複查BUN 6.5 mmol/L,CRE 155 μmol/L.至今隨訪8年,免疫抑製方案為他剋莫司+醋痠潑尼鬆(5 mg)的二聯方案,他剋莫司穀濃度維持3.0 ～ 4.5 μg/L,長期口服拉米伕定,0.1g,1次/d.移植肝、胰、腎功能均正常,乙肝病毒DNA定量＜1000 U/ml,一般情況良好. 結論 原位揹馱式肝移植及胰液空腸引流的胰-十二指腸及腎一期聯閤移植的技術安全,箇體化用藥及規律隨訪是患者穫得長期存活的重要因素.
목적 분석1례간염후간경화병발뇨독증반이도소의뢰형당뇨병환자행간、이、십이지장、신일기연합이식후적수방결과화림상특점. 방법 환자남성,43세.진행성소수병뇨량감소2개월,우2004년11월20일입원.실험실검사:병안산전안매(ALT) 117 U/L,천동안산전안매(AST) 113 U/L,백단백(ALB) 26.9 g/L,총담홍소(TBIL) 102 μmol/L,뇨소담(BUN) 23.6 mmol/L,혈기항(CRE) 664 μmol/L,을간계렬시소삼양,공복혈당10.8 mmol/L,찬후혈당18.4 mmol/L.B초급CT검사시간경화,대량복수,비종대,이선두부대,주이관확장,쌍신위축;신동태현상검사시쌍신공능엄중손해,근사무공능.진단위간염후간경화병발뇨독증반이도소의뢰형당뇨병.2005년1월17일재전마하행간、이、십이지장급신일기연합이식술,술중채용원위배타식방법진행간이식,이식이선적외분비채용공장내인류,이식신장치우좌가와.응용파석리단항진행면역유도,토항인흉선세포면역구단백치료급성배척반응.출원후장기규률수방. 결과 술후1주복사ALT 57 U/L,AST43 U/L,ALB 36.9 g/L,TBIL 22 μmol/L,BUN 26.5 mmol/L,CRE 683.μmol/L,완전정용이도소,련속성신장체대치료유지내배경은정.술후제16천인급성배척반응절제이식신장,우원이식부위진행제2차신이식,술후제3천복사BUN 6.5 mmol/L,CRE 155 μmol/L.지금수방8년,면역억제방안위타극막사+작산발니송(5 mg)적이련방안,타극막사곡농도유지3.0 ～ 4.5 μg/L,장기구복랍미부정,0.1g,1차/d.이식간、이、신공능균정상,을간병독DNA정량＜1000 U/ml,일반정황량호. 결론 원위배타식간이식급이액공장인류적이-십이지장급신일기연합이식적기술안전,개체화용약급규률수방시환자획득장기존활적중요인소.
Objective To investigate the long-term effect of triple organ transplantation (liver,kidney,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 procedure.Methods A 43-year-old male patient presented with progressive ematiation and hypourocrinia for 2 months.Blood test showed ALT 117 U/L,AST 113 U/L,ALB 26.9 g/L,TBIL 102 μmol/L,BUN 23.6mmol/L,CRE 664 μmol/L.The fasting and postprandial plasma glucose were 10.8 mmol/L and 18.4mmol/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 exocrine pancreatic insufficiency and insulin-dependent diabetes related to chronic pancreatitis (CP) after developing end-stage hepatic and renal failure.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 donor kidney was placed in left iliac fossa.Patient was prescribed prednisone,tacrolimus,mycophenolate mofetil,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 function and CRRT (Continuous Renal Replacement Therapy) was used.Subsequently,the donor kidney was removcd 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 renal functions.The immunosuppressive drugs FKS06+Pred was used and the tacrolimus level maintained 3.0-4.5 μmol/L,Lamivudine was long-term used to inhibition HBV virus duplication.Conclusions Simultaneous piggyback orthotopic liver combined with heterotopic pancreas-duodenum and renal transplantations is a good therapeutic option for patients with exocrine pancreatic insufficiency and insulin-dependent diabetes combined with hepatic and renal failure.
