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肝移植是目前公认的治疗终末期肝病的最有效措施，而如何让移植受者获得免疫耐受状态则是肝 移植科医师追求的最终目标。了解最新的国际多中心临床经验以及相关基础研究结果，有助于我们更深入地认识 免疫耐受，从而为移植受者制定更加妥善的治疗方案。本文综合国际核心期刊报道的内容，从临床免疫耐受的可 行性、免疫耐受的诱导和维持、免疫耐受诱导方案的制定及寻找合理的免疫状态的相关监测指标等方面作一综述， 并对今后的研究方向作出展望。 [ABSTRACT FROM AUTHOR]

Objective To evaluate the application value of perioperative interventional strategy guided by enhanced recovery after surgery (ERAS) in elderly recipients undergoing liver transplantation. Methods Clinical data of 405 liver transplant recipients were retrospectively analyzed. According to age, all recipients were divided into the elderly (≥60 years, n=122) and non-elderly groups (<60 years, n=283). All patients received perioperative interventions under the guidance of ERAS. Intraoperative and postoperative indexes, incidence of postoperative complications and discharge were analyzed between two groups. Results There were no significant differences in the duration of anesthesia, operation time, anhepatic phase, hemorrhage volume, blood transfusion volume, lactic acid level before abdominal closure, ventilatorassisted time, the length of intensive care unit (ICU) stay, Caprini score, CHIPPS score, time of gastric tube, urinary tube and drainage tube removal, time to first drinking, time to first physical activity and time to first flatus between two groups (all P>0.05). In the elderly group, the time to first feeding was later than that in the non-elderly group (P<0.05). There were no significant differences in the incidence of fever, ascites, pulmonary infection, delayed gastric emptying, hemorrhage and inactive venous thrombosis between two groups (all P>0.05). No significant differences were observed in the levels of aspartate aminotransferase, total bilirubin, direct bilirubin, serum creatinine before discharge and total length of hospital stay between two groups (all P>0.05). The alanine aminotransferase level in elderly recipients was lower than that in nonelderly counterparts, and the difference was statistically significant (P<0.05). No unplanned reoperation was performed within postoperative 30 d in two groups. There was no significant difference in the re-hospitalization rate within 30 d after discharge (P>0.05). Conclusions ERAS-guided interventional strategy contributes to perioperative recovery of elderly recipients undergoing liver transplantation, and yields equivalent postoperative recovery between elderly and non-elderly recipients. Objective To evaluate the application value of perioperative interventional strategy guided by enhanced recovery after surgery (ERAS) in elderly recipients undergoing liver transplantation. Methods Clinical data of 405 liver transplant recipients were retrospectively analyzed. According to age, all recipients were divided into the elderly (≥60 years, n=122) and non-elderly groups (<60 years, n=283). All patients received perioperative interventions under the guidance of ERAS. Intraoperative and postoperative indexes, incidence of postoperative complications and discharge were analyzed between two groups. Results There were no significant differences in the duration of anesthesia, operation time, anhepatic phase, hemorrhage volume, blood transfusion volume, lactic acid level before abdominal closure, ventilatorassisted time, the length of intensive care unit (ICU) stay, Caprini score, CHIPPS score, time of gastric tube, urinary tube and drainage tube removal, time to first drinking, time to first physical activity and time to first flatus between two groups (all P>0.05). In the elderly group, the time to first feeding was later than that in the non-elderly group (P<0.05). There were no significant differences in the incidence of fever, ascites, pulmonary infection, delayed gastric emptying, hemorrhage and inactive venous thrombosis between two groups (all P>0.05). No significant differences were observed in the levels of aspartate aminotransferase, total bilirubin, direct bilirubin, serum creatinine before discharge and total length of hospital stay between two groups (all P>0.05). The alanine aminotransferase level in elderly recipients was lower than that in nonelderly counterparts, and the difference was statistically significant (P<0.05). No unplanned reoperation was performed within postoperative 30 d in two groups. There was no significant difference in the re-hospitalization rate within 30 d after discharge (P>0.05). Conclusions ERAS-guided interventional strategy contributes to perioperative recovery of elderly recipients undergoing liver transplantation, and yields equivalent postoperative recovery between elderly and non-elderly recipients. [ABSTRACT FROM AUTHOR]

Objective To investigate the guiding role of quantitative evaluation system of immune status in the individualized management of immunosuppressants for the recipients after liver transplantation. Methods Clinical data of 239 liver transplant recipients were retrospectively analyzed. MingDao Immune Cell Analysis (MICA) was established. All recipients were divided into two groups according to the adjustment regimens of immunosuppressants. The immunosuppressant regimen was adjusted according to MingDao Immune System Score (MISS) in the MISS group (n=84), and the medication plan was empirically adjusted during the same period in the control group (n=155). According to the time of postoperative detection (t), the recipients in the MISS group were divided into subgroup A (t ≤ 28 d, n=78), subgroup B (28 d< t ≤ 6 months, n=68), subgroup C (6 months < t ≤ 12 months, n=18), subgroup D (12 months < t ≤ 24 months, n=18) and subgroup E (t >24 months, n=19). In the MISS group, postoperative MISS scores of recipients in subgroups A-E were analyzed. The incidence of acute rejection and opportunistic infection and the overall survival rate were statistically compared between the MISS and control groups. Results The MISS scores in subgroups A-E were -7.0 (-13.2, -2.0), -2.0 (-5.8, 1.8), -0.5 (-7.3, 2.8), -2.0 (-4.5, 3.3) and -3.0 (-6.0, 1.0), respectively. The immune status of the recipients was gradually improved over postoperative time, and the difference between two groups was statistically significant (P<0.05). In the MISS group, 15% (13/84) of the recipients developed acute rejection, and 27% (42/155) in the control group, and the difference was statistically significant (P<0.05). In the MISS group, the MISS score of the recipients with acute rejection was 0 (-2.5, 3.5), and -5.0 (-12.0, -1.0) for their counterparts without acute rejection, and the difference was statistically significant (P<0.05). In the MISS group, 2% (2/84) of the recipients presented with postoperative opportunistic infection, and 9% (14/155) in the control group, and the difference was statistically significant (P<0.05). In the MISS group, the 1- and 3-year overall survival rates were 86.9% and 79.8%, and 83.2% and 76.8% in the control group, and no significant difference was observed between two groups (P>0.05). Conclusions MICA and MISS score may reflect the immune status of liver transplant recipients, and guide the individualized management of administration of immunosuppressants after liver transplantation. [ABSTRACT FROM AUTHOR]

Objective To evaluate the changes and significance of lymphocyte subsets in the recipients with acute rejection after liver transplantation. Methods The recipients presenting with acute rejection after liver transplantation were assigned into the rejection group (n=17), and their counterparts with stable liver function were allocated into the control group (n=17) according to the ratio of 1∶1 by propensity score matching method. The incidence of acute rejection after liver transplantation was analyzed, and the concentration of tacrolimus in the recipients was compared between two groups. The absolute value and proportion of lymphocyte subsets in peripheral blood were compared between two groups. The diagnostic value of lymphocyte subsets for acute rejection after liver transplantation was assessed by the receiver operating characteristic (ROC) curve. The absolute value and proportion of lymphocyte subsets in the rejection group were compared before and after treatment. Results Among 17 recipients in the rejection group, 4 cases developed acute rejection within postoperative 28 d, and 13 cases had acute rejection within postoperative 29-180 d. No significant difference was noted in the tacrolimus concentration between two groups (P=0.295). Compared with the control group, the proportions of peripheral blood T cells, CD4+ T cells, B cells and natural killer (NK) T cells were significantly increased in the rejection group (all P<0.05). The elevated proportion of NKT cells in the early stage after liver transplantation was an independent risk factor for acute rejection following liver transplantation[odds ratio (OR) 1.774，95% confidence interval (CI) 1.059-2.971，P=0.029]. ROC curve analysis showed that the area under curve (AUC) of CD4+ T cells, B cells and NKT cells was 0.76, 0.73 and 0.77, respectively. The AUC of combined use of CD4+ T cells, B cells and NKT cells was 0.89, with a cut-off value of 0.69, sensitivity of 0.706 and specificity of 0.941. After corresponding treatment, all recipients were gradually recovered, and liver functions were eventually restored to normal in the rejection group. After treatment, the proportion of T cells, CD4+ T cells, CD8+ T cells and NK cells was significantly decreased (all P<0.05). Conclusions The elevated proportion of NKT cells indicates an increased risk of acute rejection after liver transplantation. Combined use of CD4+ T cells, B cells and NKT cells may deliver early detection and diagnosis of acute rejection after liver transplantation. [ABSTRACT FROM AUTHOR]

Objective To explore the clinical efficacy of liver transplantation for severe liver disease. Methods The clinical data of 51 patients who underwent liver transplantation for severe liver disease were retrospectively analyzed. The general intraoperative conditions were observed, including operation duration, warm ischemia time, cold ischemia time, anhepatic phase, bleeding volume, blood transfusion volume, plasma transfusion volume and so on. The changes in indexes such as total bilirubin (TB), prothrombin time activity (PTA), and prothrombin time international normalized ratio (PT-INR) were observed before operation and at 3 d, 1 week and 2 weeks after operation. The postoperative survival and occurrence of complications were analyzed. The indexes that might affect the prognosis of patients with severe liver disease were analyzed by Cox regression analysis. Results For the 51 patients, operation duration, warm ischemia time and cold ischemia time was 8 (7, 9) h, 3 (2, 3) min and 6 (5, 8) h respectively, intraoperative anhepatic phase was 80 (70, 100) min, intraoperative bleeding volume was 1 000 (550, 1 500) mL, and intraoperative blood transfusion volume was 1 200 (200, 1 600) mL. Postoperative TB, PTA, PT-INR and other indexes improved significantly compared to those preoperatively. Among the 51 patients, 10 cases died, with the death causes of multiple organ failure and severe infection (7 cases), renal insufficiency (2 cases), and cardiovascular complications (1 case). Survival rates at 1 month and 1 year post-transplantation for patients with severe liver disease were 82% and 80%, respectively. Cox regression analysis suggested that abnormal preoperative PTA and PT-INR were the risk factors for post-transplantation death in patients with severe liver disease. Conclusions Liver transplantation significantly improves the survival rate for patients with severe liver disease, perioperative infection prevention and treatment as well as multiple organ function management play key roles in improving post-transplantation survival rate in patients with severe liver disease. [ABSTRACT FROM AUTHOR]