Objective To summarize the experiences of 26 case of liver transplantation across ABO barrier in our hospital,and on the basis of literature review,further discuss the feasibility of ABO-incompatible liver transplantation.Methods The clinical data of 395 caces of liver transplantation since January 2009 to December 2012 were retrospectively analyzed.Of them,26 cases were across ABO blood group,including 17 ABO-compatible (ABO-C) and 9 ABO-incompatible (ABO-I).The patients were grouped as ABO-identical(ABO-Id,n =369),ABO-compatible(ABO-C,n =17) and ABO-incompatible(ABO-I,n =9),patient survivals and the rates of biliary complications,vascular complications,infection,acute and chronic rejection were compared among 3 groups.Results the 1-year and 2-year patient's survival rates were 87.3％,82.4％,88.9％,and 78.3％,70.6％,66.7％ in ABO-Id,ABO-C,ABO-I group,respectively.The accumulative survival rates among 3 groups were not significantly different (log rank test,P ＞ 0.05).The incidence of general complications and biliary complications was higher in ABO-I than in ABO-Id(P =0.035,P =0.001).There were no significant differences among the 3 groups in vascular complications,infection,acute and chronic rejection (P ＞ 0.05).Conclusions Although the complication incidence is higher in ABO-incompatible liver transplantation,the patient survival rate is compatible to ABO-compatible liver transplantation.Thus,for patients who are waiting grafts for a long time or need emergent liver transplant,ABO-incompatible liver transplantation is safe and feasible.

Objective To analyze related perioperative risk factors of acute respiratory distress syndrome (ARDS) early after orthotopic liver transplantation (OLT).Methods The cases from the recipients having undergoing OLT,aged from 15 to 65 years and having no chronic respiratory diseases and hyoxemia were collected.The exclusive criteria were as follows:(1) the patients dead or automatic discharging at the day after the OLT or during the OLT; (2) the patients suffered from severe surgical technic complications; (3) initial poor graft function occurred; (4) marginal donor; (5) pulmonary wedge pressure (PAWP)＞ 2.394kPa.251 patients were enrolled in this analysis,who were grouped according to whether they developed ARDS (group B) or not (group A) in the first postoperative day.The analyzed factors were as follows:(1) the sex,age and weight of the recipients; (2) preoperative variables of recipients:Child-Pugh and Model for end-stage liver disease (MELD) score,left vent ricular ejection fractions,oxygenation index,the serum levels of creatinine,BUN,TB,albumin,prealbumin,fibrinogen and hemoglobin,white blood cells (WBC),platelet count and international normalized ratio (INR) ; (3) the variables of donator:age,the time of warm and cold ischemia; (4) the intraoperative variables:operative time,anhepatic phase,the volumes of hemorrhage and blood-transfusion (red cell suspension and plasma),transfusion volume; (5) postoperative variables of recipients:the serum levels of creatinine,blood urea nitrogen (BUN),total bilirubin (TB),albumin,alanine aminotransferase (ALT),sodium and potassium,fibrinogen and hemoglobin,WBC,platelet count and INR.Results The mild ARDS incidence early after OLT was 25.5 ％ (65/251) and the moderate or severe was 4.8％ (12/265).Single factor analysis showed that the factors having significant difference between group A and group B were as follows:the age of the recipients,preoperative variables (Child-Pugh and MELD score,the preoperative serum levels of BUN,TB,prealbumin,fibrinogen and hemoglobin,WBC,platelet count and INR),the intraoperative variables (the volumes of hemorrhage and blood-transfusion including red cell suspension and plasma) and the postoperative variables (the serum levels of BUN,TB,sodium,fibrinogen and hemoglobin,WBC,platelet count and INR).The significant factors were put to the analysis of LOGISTIC regression,and the results showed that the age of recipients,preoperative Child-Pugh score,BUN and INR,intraoperative hemorrhage volume,postoperative serum level of sodium were the independent risks contributing to ARDS.Conclusion The mild ARDS incidence early after OLT was high but the the moderate or severe incidence was low.The age of recipients,preoperative Child-Pugh score,BUN and INR,intraoperative hemorrhage volume and postoperative serum level of sodium may be the main risk factors to lung injury after OLT.

Recent studies have demonstrated that complement contributes to the development of autoimmune diabetes. However, the mechanisms remain unknown. Herein, using a model of streptozotocin (STZ)-induced diabetes, we found the presence of immune tolerance to self islet in complement C3-deficient mice after STZ. Higher number of CD4+CD25+ regulatory T cells (Tregs) with characteristics of expressing Foxp3 was observed in C3-/- mice. These C3-/- Tregs exhibited enhanced suppressive capacity to effector cell proliferation. The central role of Tregs was further evidenced by that depleting these cells using anti-CD25 antibody dramatically abrogated the preventive effects of C3 deficiency on STZ-induced diabetes. Importantly, transforming growth factor-β (TGF-β) was a key factor for Treg-mediated immune suppression as blocking TGF-β activity reversed suppressive capacity of Tregs in vitro and diabetes-resistant effects of C3 deficiency in vivo. These findings suggest that resistance to overt diabetes in STZ-treated C3-/- mice involves a population of Tregs in TGF-β-dependent manner.

Objective To explore the monitoring and the individualized adjustment of cellular immunology function in the recipients infected with pan-drug resistant Acinetobacter baumannii(PDR-Ab)after liver transplantation.Methods We retrospectively summarized the infection and the prognosis of PDR-Ab in 299 cases of liver transplantation performed from Jan.2008 to May 2010.The absolute number of T lymphocytes and ATP level within CD4+ T cells were monitored,and T cell immunology function(TCIFS)was scored.According to different immunology adjusting proposals,14 cases of PDR-Ab infection were divided into 2 groups:(1)traditional group,routine anti-infective therapy;(2)individualized group.Individualized immunology adjustment was made according to the score of TCIFS besides routine therapy.Results There was no significant difference in age,MELD and Child-pugh score between two groups.The peri-operative bleeding volume in individualized group was more than that in traditional group(P<0.01).There was no significant difference in TCIFS score between two groups at 1st week after transplantation and the onset of the PDR-Ab infection.However,the score in individualized group was apparently higher than that in traditional group when anti-infection therapy ended(P<0.05).The difference in the recovery rate between two groups was significant(P<0.05).No rejection happened in two groups.Conclusion It is an effective way to decrease the mortality of PDR-Ab infection after liver transplantation that the individualized adjustment of immunosuppression protocols is guided by grading quantitatively the cellular immunology function according to the absolute number of T lymphocytes and ATP level within CD4+ T cells.

Objective To investigate some improvements in the surgical techniques of adult-to-adult living donor liver transplantation( A-A LDLT) without the middle hepatic vein(MHV) for hepat-ic vein reconstruction. Methods The retrospective analysis was made on the clinical data of 11 recipi-ents who underwent the operation in A-A LDLT including the hepatic vein reconstructed in right liver lobe without MHV from June 2007 to January 2008. The key techniques included reconstructing out-flow of graft on shaping the tips of vena cava and right hepatic veins, cadaveric vein allografts stored in 4℃ UW solution within 7d being used for significant-sized hepatic vein reconstruction such as tributa-ries of the middle hepatic vein from V5, V8 and right inferior hepatic vein. Results 10 cases success-fully underwent reconstruction of outflow of graft on shaping the tips of vena cava and right hepatic veins and the outflow reconstruction ratio of V5, V8 and right inferior hepatic vein was 81. 8% (9/11), 7 one-vein reconstruction, 1 two-vein reconstruction and 1 three-vein reconstruction. 1 recipient died of renal failure and pulmonary infection 14 days after operation without venous outflow obstruc-tion. Doppler ultrasonography showed no thrombosis and the blood flowed smoothly in the right he-patic vein of other 8 recipients during the 9th to 15th mouth of follow-up. The cumulative patency rates of these 8 survivals for interposition vein grafts were 100% (11/11), 72. 7 %(8/11), 54. 5%(6/11) and 36. 5%(4/11) in 1, 3, 6 and 9 mouths, respectively. The regeneration of paramedian sectors was equivalent. Conclusion Shaping the tips of vena cava and right hepatic veins and using cadaveric vein allografts in adult-to-adult right lobe living donor liver transplantation for hepatic vein reconstruc-tion are both safe,simple and effective methods.This approach can be recommended.

Objective To explore the relationship between ATP content in CD4+ T lymphocytes and acute rejection after liver transplantation(LT). Methods This study contained 77 patients who received LT from February to October 2009, They were divided into AR (acute rejection) and NAR (non-acute rejection) groups while 56 healthy people were enrolled to serve as the control group.Blood specimens were collected preoperatively and at 1, 2 and 4 weeks postoperatively. For the AR group, specimens were also collected on the day when AR occurred and 1 week after steroid bump together with that of the healthy people. ImmuKnowTM test kits for immune cell function were used to assay the ATP value. Results ATP values within CD4+T lymphocytes were elevated significantly in each group compared with those preoperatively. Peak level was reached in the AR group and was significantly higher than that of the contemporary NAR group (P＜0.05). ROC curve analysis showed that the obvious elevation of the ATP value within CD4+ T lymphocytes 1 week postoperatively had better sensitivity and specificity in diagnosing AR. The ATP sensitivity rate for early AR was 84.6 %and specificity rate 81 %. The ATP value within CD4+ T lymphocytes on the day of AR occurrence had a positive relationship with the rejection acting index(RAI), while relative index (r) was 0. 876(P＜0.05). After the steroid dump treatment, AR in all the patients was reversed and the ATP value declined significantly as compared with the control group and the day when AR occurred(P＜0. 05).Conclusion During the postoperative period, the dynamic change of ATP value within CD4 + T lymphocyte had a close relationship with acute rejection after liver transplantation. Thus, it might be used as a feasible and noninvasive monitoring index for diagnosing AR and the effectiveness of the anti-rejection treatment.

Objective To investigate the surgical options for the management of portal vein thrombosis (PVT) during liver transplantation and its impact on the outcome of patients. Methods 773 cases of liver transplantation were analyzed retrospectively. PVT occurred in 107 patients, inclu-ding 59 of grade Ⅰ ,33 of grade Ⅱ, 12 of grade Ⅲ and 3 of grade Ⅳ. Simple thrombectomy or thrombus-extraction was performed in grade Ⅰ and Ⅱ. 12 patients with grade Ⅲ received thrombus-extraction or using the donor iliac vein to act as a bridge between the donor portal vein and host superior mesenteric vein. Two cases of grade Ⅳ received a modified cavo-portal hemitransposition and one case received portal-vena coronaria varication anastomosis. Results Liver function had a good recover and the perio-perative mortality is 4. 3% in grade Ⅰ and Ⅱ. In grade Ⅲ , 5 cases received thrombus-extraction had a normal liver function after transplantation and had no died. 2 cases among the other 7 cases using por-tal vein reconstruction had bad liver function and died. The liver function recovered well after trans-plantation and there was no died in grade Ⅳ. Conclusions PVT is not a contraindication for liver transplantation. Good results can be obtained by applying reasonable operative procedures individually.

Objective To explore the dynamic changes of the expression of chemokine IP-10 and its receptor CXCR3 before and after liver transplantation in rats and to analyze the relationship between the role and the acute rejection(AR).Methods The model of orthotopic liver transplantation(OLT) of rats was established by two-cuff technique.Rats were randomed into 4 groups: Operation injury,OLT without AR,OLT with AR and OLT treated by FK506.The dynamic expression of IP-10 and CXCR3 was measured 1 day prior to OLT and 1,3,5,7 days and after OLT.Results ①The expression of chemokine IP-10 and its receptor CXCR3 in peripheral blood increased significantly in each group after operation.②On the fifth day after OLT,the concentration of chemokine IP-10 and the expression of CXCR3 in AR group were significantly higher than those in the other groups(P0.01);③The IP-10 and CXCR3 in peripheral blood was significantly correlated with RAI on the 7th day after OLT,the correlation coefficients were 0.89 and 0.92(P0.05).Conclusion The dynamic expression of chemokine IP-10 and its receptor CXCR3 in the peripheral blood is closely related to acute rejection and can be used as a diagnostic indicator.

Recent studies have shown that Th17 cells, as a distinct lineage from Th1 and Th2 subsets, play an obligatory role in the pathogenesis of autoimmune diseases. It is well known that immunotherapy with Complete Freund's adjuvant (CFA) is effective in preventing from the onset of autoimmune diabetes in nonobese diabetic (NOD) mice. In the present study, we investigated whether CFA treatment restrained Th17 development and down-regulated Th17-related cytokine production in NOD mice. Th17-related cytokines (i.e. IL-17A, IL-17F, IL-21, IL-22, IL-23, IL-6, TGF-β) production in splenocytes was decreased dramatically on day 18 following CFA immunization. This effect was also observed at 10 and 20 week after adjuvant treatment. Injection of IL-17 into CFA-treated diabetes-free mice led to occurrence of overt diabetes, indicating that therapeutic effects of adjuvant treatment may be partially due to suppressing Th17 commitment. Interestingly, the main producer of IL-17 resided in a population of myeloid cells, which negatively expressed makers of neutrophil or macrophages. IL-23 stimulation did not alter the distribution of IL-17 in myeloid cells. Furthermore, this pattern of IL-17 expression was also present in Balb/c and C57BL/6 strains. These findings may have important implications for understanding of mechanisms underlying adjuvant treatment on autoimmune diseases.

Background:Liver transplantation (LT) was advocated as a salvage treatment of choice for patients with unresectable hepatocellular carcinoma (HCC). This study was designed to assess the eligibility of LT criteria for patients with HCC and to analyze the factors influencing the recurrence of HCC following LT, aiming to further improve the efficacy of LT for patients with HCC.Methods:Clinical data of 255 patients with HCC who underwent LT between December 2001 and December 2007 at Shanghai Changzheng Hospital, China were retrospectively analyzed.Results:Among these cases, 75 patients were within the Milan criteria and 180 were beyond it; 110 patients were within the University of California, San Francisco (UCSF) criteria, while 145 were beyond it. The difference in overall survival rates was not only significant between the patients within and beyond the Milan criteria but also between patients within and beyond the UCSF criteria. Tumor-node-metastasis (TNM) staging, portal vein tumor thrombus (PVTT), and the pre-operative alpha-fetoprotein (AFP) level were independent risk factors affecting the overall survival and post-operative recurrence-free survival rates of patients with HCC. Pathological staging and pre-operative local treatment of HCC had no obvious correlation with the post-operative recurrence-free survival rate.Conclusion:LT is an effective treatment modality for HCC. The UCSF criteria did not show better effectiveness than the Milan criteria. TNM staging, PVTT, and the pre-operative AFP level are closely related to the recurrence of HCC following LT.

Objective:To evaluate the efficacy and safety of microemulsified cyclosporine(Neoral)and tacrolimus(FK506) for immunodepression after Iiver transplantation.Methods:According to the including criteria,fifteen randomized controlled trials were enrolled in this analysis.The data of trial design,characteristics of the subjects,and findings of the studies were reviewed and analyzed by RevMan 4.2.8 software.Results:The patient survival rate,graft survival rate,incidence of nephrotoxicity,and incidence of infection were not significantly different between Neoral and FK506 groups,with the relative risk and(95% CI,P)being 0.99(0.96-1.02,0.37),0.97(0.92-1.03,0.30),0.99(0.87-1.13,0.86)and 1.08(0.97-1.20, 0.16),respectively.The incidences of hypertension(1.34[1.15-1.55,0.000 1])and acute rejection(1.15[1.06-1.25,0.001]) were significantly lower in the FK506 group,with no significant difference found in the degree of acute rejection(1.00[0.92- 1.22],0.98).Interestingly,the incidence of diabetes was significantly higher in the FK506 group within 1 year after the operation,but was similar to that of the Neoral group thereafter,with relative risk(95%CI,P)being 0.72(0.62-0.83,0.0001) and 1.47(0.98-2.20,0.06),respectively.Conclusion:The 2 drugs have comparable patient/graft survival rates and incidences of nephrotoxicity and infection.FK506 can better reduce the incidence of acute rejection,but can not alleviate the degree of rejection.FK506 should be recommended for patients suffering from hypertension after liver transplantation and Neoral should be recommended for patients with diabetes.

Objective To evaluate the therapeutic effects of liver transplantation (LT) for cholangiocarcinoma(CC)and analyze the prognostic factors.Methods From December 2001 to December 2006,234 patients receiving LT for hepatic carcinoma in our institute were enrolled as a basis of comparative study for 6 CC patients undergoing LT during the same period.Results These 6 patients were followed-up from 1 to 56 months.Five patients died and one recurred.The 0.5-,1-and 2-year patient cumulative survival rates were 4/6,3/6 and 1/6,respectively.The 0.5-,1-and 2-year tumor-free survival rates were 3/6,2/6 and 1/6,respectively.The average patient or tumor-free survival time were both(14±4) months.Conclusion The prognosis of cholangioearcinoma patients after LT iS poor.

早期的多数肝移植指征将年龄上限制定为50～55岁[1],随着手术技术的进步和免疫抑制手段的发展,肝移植的受体年龄也在不断增长.如今,越来越多的高龄患者接受了肝移植手术,已有受体年龄为78岁的肝移植病例报道[2].为了进一步探讨年龄对肝移植的影响,我们对上海长征医院肝移植中心≥60岁老年患者的肝移植情况进行了分析.

Objective:To study the outcomes of a modified cavoportal hemitransposition technique for liver transplantation in treatment of diffuse portal vein thrombosis.Methods: Two patients with diffuse portal vein thrombosis received liver transplantation by modified cavoportal hemitransposition.Anastomosis between the native inferior vena cava and the graft coeliomesenteric vein and adjuvant anastomosis between the native portal vein and graft spleen vein were performed to reconstruct the blood flow of portal vein.The post-operation liver function,portal flow,renal insufficiency,edema of lower extremities,and the varices of esophagus or gastric fundus were observed.Results: The operation was successful in both cases,with normal post-operation liver function and satisfactory portal flow.There was no complication such as renal insufficiency,edema of lower extremities,and varices of esophagus or gastric fundus.Conclusion: This modified cavoportal hemitransposition technique in liver transplantation is proved effective for diffuse portal vein thrombosis.