Abstract
Objective To discuss the preservation solution (PS) contamination and initial experience of liver transplantation from organ donation by citizens after death and initial experience. Methods The 78 liver transplant recipients were divided into positive group and negative group based on the finding of the culture of PS. The positive group received the sequential therapy of antibiotics with ertapenem and imipenem for one week, and the negative group stopped using imipenem. The situation of PS contamination and infection after liver transplantation and prognosis during the follow-up 3 months of the recipients were analyzed. Results PS culture positive rate was 41.03%, and 33 strains of pathogens were isolated. The most common pathogenic bacteria were gram-negative bacilli (9 strains, 27.27%) and <i>coagulase –negative staphylococci</i> (9 strains, 27.27%). The infection rate after liver transplantation was 31.25% and 13.04%, respectively, in positive group and negative group (χ<sup>2</sup>=3.837, <i>P</i>=0.048). The most frequent infection sites were lower respiratory tract (5 cases, 31.25%), abdominal cavity (5 cases, 31.25%) and surgical incision (4 cases, 25.00%). There was no significant difference in postoperative infection rate among patients with different CTP, MELD and surgical methods (<i>P</i>>0.05). One case (1.28%) was infected with the same pathogenic bacteria as PS contamination 3 weeks after liver transplantation, and died of multiple organ failure. There was no significantly difference in the acute rejection rate (1,3.13% and 2, 4.35%) and mortality (2,6.25% and 5,10.87%) between the two groups (<i>P</i>>0.05). Conclusion Contamination of the PS is frequent in liver transplantation, and it is the risk factor for postoperative infection of recipients. Early targeted antimicrobial treatment against pathogens cultured from PS play a positive role in reducing the contamination-associated infection rate after liver transplantation.
Highlights
摘要:目的:探讨公民逝世后器官捐献肝脏保存液(preservation solution, PS)污染及预防肝移植术后感染初步经验。 方法:根据捐献肝脏PS培养结果将78例公民逝世后器官捐献肝移植受者分为阳性组和阴性组。阳性组围手术期序贯应 用厄他培南和亚胺培南,疗程为一周;阴性组停用亚胺培南。对保存液污染病原菌分布、术后感染和预后情况进行统 计分析。结果:PS培养阳性率41.03%,分离出33株病原菌,最常见的病原菌是革兰氏阴性杆菌(9株,27.27%)和凝固 酶阴性葡萄糖球菌(9株,27.27%)。阳性组和阴性组肝移植受者术后感染率分别为31.25%和13.04%(χ2=3.837,P=0.048)。 感染例次最多的部位是下呼吸道(5例,31.25%)和腹腔(5例,31.25%),其次是手术切口(4例,25.00%)。不同 肝功能Child-Turcotte-Pugh(CTP)、终末期肝病模型(model of end stage liver disease, MELD)评分以及手术方式患者 术后感染率差异无统计学意义。1例受者术后3周发生与PS污染相同的病原菌感染,并因多脏器功能衰竭而死亡。在术 后随访3个月内,阳性组和阴性组患者急性排斥反应率和死亡率分别为3.13%(1例)、4.35%(2例)和6.25%(2例)、 10.87%(5例),差异均无统计学意义(P>0.05)。结论:公民逝世后捐献肝脏PS经常受到污染,PS污染是受者术后 感染的危险因素。早期针对性抗菌素治疗对降低公民逝世后捐献肝脏PS污染相关的感染有着积极作用。
本研究中,5例公民逝世后捐献肝脏PS分离出酵母菌, 发生率6.4%,较其他研究结果稍高。通过移植物传播的念 珠菌症引起的真菌性动脉瘤炎与肾移植术后高发病率和 高死亡率具有相关性[24,25]。然而,在肝移植患者中鲜有 相关研究和报道。在本研究中,5例PS培养阳性受者术后 恢复顺利,未发生来自于PS污染的酵母菌感染,可能与我 中心早期、足量和长疗程应用抗真菌药物有关。
Summary
摘要:目的:探讨公民逝世后器官捐献肝脏保存液(preservation solution, PS)污染及预防肝移植术后感染初步经验。 方法:根据捐献肝脏PS培养结果将78例公民逝世后器官捐献肝移植受者分为阳性组和阴性组。阳性组围手术期序贯应 用厄他培南和亚胺培南,疗程为一周;阴性组停用亚胺培南。对保存液污染病原菌分布、术后感染和预后情况进行统 计分析。结果:PS培养阳性率41.03%,分离出33株病原菌,最常见的病原菌是革兰氏阴性杆菌(9株,27.27%)和凝固 酶阴性葡萄糖球菌(9株,27.27%)。阳性组和阴性组肝移植受者术后感染率分别为31.25%和13.04%(χ2=3.837,P=0.048)。 感染例次最多的部位是下呼吸道(5例,31.25%)和腹腔(5例,31.25%),其次是手术切口(4例,25.00%)。不同 肝功能Child-Turcotte-Pugh(CTP)、终末期肝病模型(model of end stage liver disease, MELD)评分以及手术方式患者 术后感染率差异无统计学意义。1例受者术后3周发生与PS污染相同的病原菌感染,并因多脏器功能衰竭而死亡。在术 后随访3个月内,阳性组和阴性组患者急性排斥反应率和死亡率分别为3.13%(1例)、4.35%(2例)和6.25%(2例)、 10.87%(5例),差异均无统计学意义(P>0.05)。结论:公民逝世后捐献肝脏PS经常受到污染,PS污染是受者术后 感染的危险因素。早期针对性抗菌素治疗对降低公民逝世后捐献肝脏PS污染相关的感染有着积极作用。 移植后感染是移植患者医院内发病和死亡的主要原 因,尤其是术后第一个月[1,2]。器官保存液(preservation solution, PS)污染是术后感染的潜在来源。PS不但可以保 持污染菌存活,而且有利于其生长,从而提供了直接感染 器官受者的传播途径[3]。一项系统性综述和meta分析显示, 总PS培养阳性率为37%(95%CI:27%~49%), PS培养致病 菌阳性的受者发生 PS 相关的感染为 10% (95%CI:7%~15%),培养阳性PS相关的感染增加移植受 者术后早期死亡率[4,5]。为研究移植物PS污染并提高移植 术后感染相关并发症的早期诊断和管理,许多器官移植中 心已常规进行移植前器官PS培养。然而,目前还没有广为 接受的指南,用于PS评估或预防性抗生素应用[6]。 者腹主动脉插管灌注高渗枸橼酸盐腺嘌呤溶液(Hypertonic Citrate-Adenine solution, HC-A液)3000ml+威斯康星大学PS (University of Wisconsin solution, UW液)1000ml,灌注高度 100cm。肠系膜上静脉插管,灌注HC-A液3000ml+UW液 500ml,灌注温度0~4°C。供肝获取后应用器官保存袋逐层密 封后0~4°C保存。供肝在手术室完成修整后留取供肝保存液 100ml进行需氧菌、厌氧菌和真菌培养。保存液有任何种类 细菌生长时,则保存液培养阳性,不考虑细菌种类。 肝移植采取非转流经典原位肝移植或背驮式肝移植 术 。 受者术中及术后 4d 应用巴利昔单抗 ( Simulect®, Novartis Pharma Schweiz AG)20mg/d进行免疫诱导。无肝 期静脉应用甲基强的松龙(5-10mg/kg)。术后第1天起, 甲基强的松龙从5mg/kg.day递减至0.3mg/kg.day,术后第8 天停用。术后第一天开始口服麦考酚钠肠溶片 (540mg,q12h),术后第四天开始口服他克莫司胶囊,并 根据患者情况进行相应调整[8]。
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