肝移植术后管理课件.pptx

1、Long-Term Management of the Successful Adult Liver Transplant(2012 Practice Guideline)感染内科科内业务学习陈洪涛2016-03-17肝移植术后管理Background-中国肝移植现状肝移植术后管理Background-中国肝移植现状肝移植术后管理Background-中国肝移植现状肝移植术后管理Background-中国肝移植现状肝移植术后管理Background-中国肝移植现状肝移植术后管理Background-中国肝移植现状肝移植术后管理Background-中国肝移植现状肝移植术后管理Backgroun

2、d-中国肝移植现状肝移植术后管理Background-中国肝移植现状Survival 85%,4years 75%,5yearsRecurrence 8%,4years肝移植术后管理Background-中国肝移植现状 杭州标准肝移植术后管理Background-美国肝移植现状 肝移植术后管理Background-美国肝移植现状 Characteristics of adult liver transplant recipients,2002&2012肝移植术后管理Background肝移植术后管理1.Liver Transplantation(LT)as a Treatment for En

3、d-stage Liver Disease/Mortality After LT/Morbidity After LT2.Complications of Portal Hypertension After LT3.Liver Tests/Vascular Thrombosis4.Immunosuppression5.Late Rejection6.Promoting Health After LT7.Bone Health.Contents肝移植术后管理8.Systemic Disease9.Nutrition and Obesity10.Oncology11.Reproductive He

4、alth12.Infectious Disease13.Immunizations14.Hepatitis（Viral,PBC/PSC,AIH,ALD,NASH/NAFLD）Contents肝移植术后管理 Recommendations and Rationales Morbidity After LT肝移植术后管理Clinical features of liver failure and portal hypertension resolve rapidly after LT.The exception is splenomegaly,which may persist for years

5、 Variceal hemorrhage is very unusual unless the patient has an occluded portal vein.The late emergence of hepatic encephalopathy suggests the development of clandestine cirrhosis or a persistent portosystemic shunt Late-onset ascites or peripheral edema may indicate stenosis of the inferior vena cav

6、a or portal vein anastomosis.Recommendations and Rationales Complications of Portal Hypertension After LT肝移植术后管理 Recommendations and Rationales LIVER TESTS 肝移植术后管理 Recommendations and Rationales Vascular ThrombosisHepatic artery thrombosis(HAT)or stenosis may present clinically after 3 months,as:int

7、rahepatic non-anastomotic strictures and/or sterile or infected fluid collections within the liver,sometimes referred to as bilomasischemic cholangiopathy or biliary cast syndrome.肝移植术后管理 Recommendations and Rationales Immunosuppression the target levels after 3 months,whole blood trough levels Tacr

8、olimus -5 to 10 ng/mL Cyclosporine-100 to 150 ng/mL Sirolimus -5 ng/mL.肝移植术后管理 Recommendations and Rationales Late RejectionCellular rejection(also known as acute cellular rejection and late-onset rejection)Liver tests nonspecific abnormalities with a rise in serum bilirubin and aminotransferases Hi

9、stologically,cellular rejection is characterized by the triad of inflammatory bile duct damage,subendothelial inflammation of the portal,central,or perivenular veins,and a predominantly lymphocytic portal inflammatory infiltrate with neu-trophils and eosinophils in addition Ductopenic rejection(also

10、 known as vanishing bile duct syndrome)肝移植术后管理 Recommendations and Rationales Late RejectionCellular rejection-Risk factors Reduction of immunosuppression(whether iatro-genic or due to noncompliance).Pre-LT autoimmune liver disease.Concurrent administration of interferon(for HCV treatment).The diffe

11、rential diagnosis includes infection,recurrent and de novo autoimmune disease,and drug toxicity 肝移植术后管理 Recommendations and Rationales Late RejectionCellular rejection-TreatmentMild:an increase in maintenance levels of immunosuppression Moderate or severe:a short course of increased immunosuppressio

12、n(eg,methyl predni-sone at 500 mg/day or prednisolone at 200 mg/day for 3 days)followed by an increase in the baseline immunosuppression Only approximately half of patients,with approximately 25%developing a further episode of cellular rejection and 25%developing ductopenic rejection.肝移植术后管理 Recomme

13、ndations and Rationales Late RejectionDuctopenic rejection-Risk factors Recurrent and unresponsive cellular rejection.Transplantation for autoimmune disease.Exposure to interferon Loss of a previous graft to ductopenic rejection.The differential diagnosis includes recurrent disease(PBC or PSC)and dr

14、ug toxicity.肝移植术后管理 Recommendations and Rationales Late RejectionDuctopenic rejection Treatmentncreased immunosuppression,and an increase in or switch to tacrolimus may be effective in some early cases.when fewer than 50%of the portal tracts contain bile ducts,the condition progresses to graft failu

15、re.肝移植术后管理Recommendations and RationalesPromoting Health After LTFrequent handwashing reduces the risk of infection with pathogens acquired by direct contact,including Clostridium difficile,community-acquired viral infections,and pathogens found in soil Shoes,socks,long-sleeve shirts,and long pants

16、should be worn for activities that will involve soil exposure and tick exposure and also to avoid unnecessary sun exposure During periods of maximal immunosuppression,LT recipients should avoid crowds to minimize exposures to respiratory illnesses Work in high-risk areas,such as construction,animal

17、care settings,gardening,landscaping,and farming,should be reviewed with the transplant team 肝移植术后管理Recommendations and RationalesPromoting Health After LTLT recipients should avoid the consumption of water from lakes and rivers LT recipients should avoid unpasteurized milk products and raw and under

18、cooked eggs and meats LT recipients should avoid high-risk pets All LT recipients should be educated about the importance of sun avoidance and sun protection through the use of a sun block with a sun protection factor of at least 15 and protective clothing.They should be encouraged to examine their

19、skin on a regular basis and report any suspicious or concerning lesions to their physicians the sustained cessation of smoking is the most important pre-ventative intervention 肝移植术后管理Recommendations and RationalesBone Health肝移植术后管理Recommendations and RationalesBone HealthIn the first 5 years after t

20、ransplantation,screening by BMD should be done yearly for osteopenic patients and every 2 to 3 years for patients with normal BMD;thereafter,screen-ing depends on the progression of BMD and on risk factors If osteopenic bone disease is confirmed or if atraumatic fractures are present,then patients s

21、hould be assessed for risk factors for bone loss;in particular,this should include an assessment of calcium intake and 25-hydroxy-vitamin D levels,an evaluation of gonadal and thyroid function,a full medication history,and thoracolumbar radiography The osteopenic LT recipient should perform regular

22、weight-bearing exercise and receive calcium and vitamin D supplements 肝移植术后管理Recommendations and RationalesSystemic DiseaseKidney Disease Urinary protein quantification using the concentration ratio of protein to creatinine in a spot urine specimen should be evaluated at least once yearly The reduct

23、ion or withdrawal of CNI-associated immunosuppression is an appropriate response to the development of CKD in LT recipientsMetabolic Syndrome Metabolic Syndrome 肝移植术后管理Recommendations and RationalesSystemic DiseaseMetabolic Syndrome The treatment of DM after LT should aim for an HBA1c target goal of

24、 40 U of blood products),Choledocho-jejunostomy,reoperation,retransplantation,hepatic iron overload,renal replacement therapy extended intervals of intensive care 肝移植术后管理Recommendations and RationalesINFECTIOUS DISEASE Fungal Infections Blood cultures are most helpful for the diagnosis of Candida bl

25、oodstream infections and Blastomyces Cryptococcal antigen testing of cerebrospinal fluid or blood is most helpful for the diagnosis of Cryptococcus Urinary histoplasmosis and Blastomyces antigens are useful for the diagnosis of disseminated histoplasmosis and blastomycosis,respectively肝移植术后管理Recomme

26、ndations and RationalesINFECTIOUS DISEASE Pneumocystis jiroveciiAll LT recipients should receive prophylaxis against P.jirovecii with trimethoprim-sulphame-thoxazole(single strength daily or double strength 3 times per week)for a minimum of 6 to 12 months after transplantation(grade 1,level A).Atova

27、quone and dapsone are the preferred alternatives for patients who are intolerant of tri-methoprim sulfamethoxazole 肝移植术后管理Recommendations and RationalesINFECTIOUS DISEASE Tuberculosis Because of the risk of a marked reduction in CNI and mTOR inhibitor levels with rifampin coadministration,the doses

28、of CNIs will need to be increased 2-to 5-fold at the initiation of treatment.Rifabutin may be substituted for rifampin to reduce the impact on drug levels,or nonrifampin-containing regimens can be consid-ered,although the duration of treatment will need to be extended.肝移植术后管理Recommendations and Rati

29、onalesINFECTIOUS DISEASE HIVHIV-infected LT recipients receiving HAART require frequent monitoring of CNI levels because of the significant interaction between antiretrovirals and CNIs Standard prophylaxis for CMV is recommended for HIV-infected LT recipients receiving HAART,and lifelong Pneumocysti

30、s pneumonia prophy laxis is the norm 肝移植术后管理Recommendations and RationalesINFECTIOUS DISEASE 肝移植术后管理Recommendations and RationalesIMMUNIZATIONS 肝移植术后管理Recommendations and RationalesIMMUNIZATIONS All LT recipients should receive an annual influenza vaccination All LT recipients should avoid live virus vac-cines(grade 1,level A).Re-immunization is indicated for some vac-cines,notably the influenza vaccine(annually)and the pneumococcal vaccine(every 3-5 years;no class or level provided)肝移植术后管理THANKS!肝移植术后管理