| Liver transplantation(LT), a method of surgery, is transplanting a integrity or partial healthy liver into a patient who suffers end-stage liver disease and make him recover. Since Starzl, the father of modern liver transplantation, successfully operated the first LT of human beings in the world in1963, the LT has underwent nearly50years’development.Every aspect of LT makes a great progression, such as Operation technique of LT, perioperative management, postoperative anti-rejection method. Orthotopic Liver Transplantation is decided as the optimal therapy for end-stage liver disease by National Institutes of Health(NIH).At present, LT with1-year’s survial rate more than80%is still the best treatment for end-stage liver disease, such as end-stage cirrhosis in adults, congenital biliary atresia in children, acute liver function failure, malignant tumor about liver.There are many research reports and consequences about prognosis relevant factors devoted by transplant centers all over the world, but the factors are not all the same, for instance human race, pathogeny, social psychological factor, graft resource, different period and drug in anti rejection.There are many domestic studies as well, but area, population,and etiology are diverse, so it is still worth studying on data in our center(72%born in GuangDong).OBJECTIVE Research of LT in our center and location of the main relevant factors relying on perioperative and surgery particularity and complexity may be a better reference for LT, improvement of prognosis and further deep comprehension of LT not only in our center in future, but also for other centrums. Currently, the contra-diction between shortage of donor and large requirement is becoming more and more serious, how to resolve the issue effectively needs all centers’endeavour in the long run.The clinical data of221cases undergoing LT between Aug.2004and Jan.2011in Nanfang Hospital were studied retrospectively.Showing the main relevant factors about early mortality may be useful for chosing the optimal recipients, distribution of grafts properly,perioperative arrangement, judgement of prognosis and elevating the survial rate after operation.METHODS1. Clinical data Survival time less than90days(contain the day ninetieth) was defined as early mortality. The clinical data of221cases underwent LT between Aug.2004and Jan.2011in Nanfang Hospital,190recipients were male(2cases received Cadaveric LT twice,2cases received Living related liver transplantation LRLT),31patients were female, The average age was50.61±1.12(20～77) years.After eliminating two improper cases, there was a total of218cases in this study group. All grafts were cadaveric donor(cardiac death) with good qualification.All cases were divided into survival group(>90d) and mortality group(≤90d), no mortal during operation.2. Etiology and techniques of LT218recipients in the research consisted of153cases with hepatocellular carcinoma(HCC),39cases with hepatic cirrhosis of decompensation,23cases with severe hepatisis,1case with primary sclerosing cholangitis,1case with Wilson’s disease,1case in Budd-Chiari syndrome. Technique contained Orthotopic liver transplantation (OTLT,1case with modifying cavoportal hemitransposition technique), Piggyback liver transplantation(PBLT), no Venous-venous bypass.3. Methods of anti rejection Induced Immune suppression during operation with Methylpred(MP). Inhibited rejection with Tacrolimus(FK506)+Mycophenolate mofetil(MMF)+MP at the first day after operation. At the sixth day with FK506+MMF+prednisone(PRED), blood drug concentration mainteined during8-12ng/mL. Shock treatment was choiced for acute rejection with MP in a large dosage or increasing FK506or changing drug, when infection was out of control, decreasing dosage and even being out of use would be performance.Since2009, some recipients only received Basiliximab+MP in operation, with FK506at the fourth day, supplied therapy effect with MMF or/and PRED depending on state of an illness. In short, conservative attitude was choosed facing patients with HCC.4. Methods of anti-Hepatitis B Virus and follow-up Lamivudine(or Entecavir) and Anti-hepatis B immunoglobulin was routinely utilized in treatment of cases with infection of Hepatitis B Virus post-operatively. Follow-up data mainly was collected through out-patient clinic, hospital and phone.5.The choice of factors46perioperative factors were Statistical analysed according to relevant references and experiences in our center.①Preoperative laboratory data(the last data before operation in patients with good status in basic state was choosed, however the last preoperative data in acute and severe patients):hemoglobin HGB(g/L), Serum creatinine Scr(μmol/L), Blood urea nitrogen BUN(mmol/L), Serum albuminALB(g/L),Serum total bilirubinTBIL(μmol/L), and so on.②Factors of recipients and graft(HE, HRS, alimentary bleeding, and infection happened in the first month before operation, CTP, MELD depended on the status before operation and laboratory data choosed):age(y), gender, blood type, HE, HRS and so on. ③Intraoperative factors and others:operation phase(hr), The anhepatic phase(min), blood transfution(ml), intraoperative urine volume(ml), the cumulative time of CVP<5cmH2O(min), the cumulative time of CVP>10cmH2O(min), technique, different stage of LT(y), and so on.6.Statistical analysis Those of significance in46pre-and intraoperative factors, which were based on univariate analysis, were analyzed by means of Logistic regression to screen for main relevant ones [measurement data analyzed with t-test or Wilcoxon rank sum test (x±s) or M(Q25%-Q75%, enumeration data analyzed with R×C tables χ2test, ordinal data with Wilcoxon rank sum test]. SPSS13.0statistical software was choosed by α=0.05significance level, P<0.05was statistical significant.RESULTS1. Consequence There were34cases in early mortality(15.6%) with mortality median time(QD12.75～44.25d),19cases in30days after operation,184cases were survival. Causes of death:12cases with infection in lung and ARDS,12patients with MODS,3recipients in graft versus host disease(GVHD),3cases in elimentary bleeding,2patients with primary graft failure,1case in abdominal cavity infection, and1in heart failure(HF).2.Univariate analysis of factors The following27relevant factors were statistically significant through univariate analysis:Scr, BUN, TBIL, ALB, IBIL, Natrium, PT, APTT, INR, Fbg, PTA, HGB, PLT, NRI, MELD, ascites, duration time of operation, blood transfusion, intraoperative urine volume, elimentary bleeding, HE, HRS, infection before operation, diabetes, CTP, and ASA.3. Multivariate analysis of factors27factors were statistical significant resulting in early mortality with univariate analysis.4factors according to Binary logistic regression analysis were mainly related factors of early mortality after LT, including preoperative hepatic encephalopathy(HE), duration time of operation, intraoperative total blood transfusion, and intraoperative total urine.CONCLUSION1. Early prognosis of Liver transplantation is stable in our center, and the main cause of early mortality is infection.2. The main etiology of recipients in our center is HBV related end-stage liver disease with the highest incidence in Hepatocellular carcinoma. Severe hepatitis is in a high mortality ratio.3. At present, the quantity of Living donor liver transplantation(LDLT) increases faster than ever before, but of Donation after cardiac death(DCD) increases little.4. There are27relevant factors connected with early mortality:Scr, BUN, TBIL, ALB, IBIL, Natrium, PT, APTT, INR, Fbg, PTA, HGB, PLT, NRI, MELD, ascites, duration time of operation, blood transfusion, intraoperative urine volume, elimentary bleeding, HE, HRS, infection before operation, diabetes, CTP, and ASA. HE, longer duration time of operation, large blood transfution, and less intraoperative urine volume are the major risk factors.5. Diverse factors could cause early mortality after LT. Postoperative death ratio can be reduced by preoperative therapy of HE, Hepatorenal syndrom(HRS) actively, and improving Coagulative function, Nutritional status, Internal environment, increase of intraoperative urine, decrease of intraoperative bleeding. |
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