Clinical research on pathogenesis and treatment of posttransplant portal hypertension and intrahepatic circulatory disorder in adult living donor liver transplantation

成人活体肝移植术后早期门静脉压（PVP）与移植物重量/体重呈负相关，但也受肝硬化、肝动脉流量和循环容量的影响。另一方面，移植后早期PVP与移植后预后有因果关系：平均PVP>20 mmHg的受者生存率降低50%。在移植后早期门静脉高压症（PH）患者中，腹水和胆红素增加，蛋白质合成减少，与PVP成比例。革兰氏阴性菌血症的发病率也增加了。然而，其预后影响随着时间的推移而降低。右肝移植物旁正中区的组织充血，归因于静脉流出中断，对PVP没有显著影响，即，与窦前PH相反，这是窦后充血。因此，这表明流入小尺寸移植物的内脏血流增加导致PVP升高和肝内门脉系统损伤，并建立了长期的病理状态。每单位组织的门静脉血流量（PVF）与移植物的相对大小呈负相关。然而，PVF本身的增加并不导致组织损伤，而是有助于血清胆红素的降低。PVF和PVP在自体肝中呈正相关。但这在移植后早期丧失，并依赖于门静脉顺应性（PVC）。PVC在移植物中高度可变，并受供体年龄和移植物热缺血的影响。为了防止由于移植后早期PH引起的组织损伤，进行脾动脉结扎（SAL）或部分门腔静脉分流（PPCS）。SAL导致PVP减少，但未导致PVF减少，PPCS还导致PVP、胆红素和腹水减少。两者都导致了更好的预后和由于腹水损失而减少的医疗费用。PPCS引起的移植物再生和蛋白质合成的一些减少的影响有待阐明。(299（文字）

Portal venous pressure(PVP) early after adult living donor liver transplantation showed an inverse correlation with graft weight per body weight, although affected also by cirrhosis, hepatic arterial flow, and circulatory volume. On the other hand, PVP early days after transplantation had a causative relationship with posttransplant prognosis : recipients with averaged PVP>20 mmHg showed 50% reduction of survival. In patients with early posttransplant portal hypertension(PH), ascites and bilirubin increased and protein synthesis decreased in proportion to PVP. Incidence of gram-negative bacteremia also increased. However, its prognostic impact decreased with time Tissue congestion in the paramedian sector of right liver graft, attributable to interrupted venous outflow, gave no significant impact on PVP, i.e., it is post-sinusoidal congestion in contrast to presinusoidal PH.Thus it was suggested that increased splanchnic flow running into a small-for-size graft causes elevation of PVP and injury to intrahepatic portal system, and establishes a prolonged pathological condition. Portal venous flow volume(PVF) per unit tissue showed an inverse relationship with relative graft size However, increased PVF per se did not lead to tissue injury, but rather contributed a reduction of serum bilirubin. PVF and PVP showed a positive correlation in the native liver. But this was lost in early posttransplant period and dependent on portal venous compliance(PVC). PVC was highly variable among grafts and affected by donor age and graft warm ischemia.To prevent tissue injury due to early posttransplant PH, splenic artery ligation(SAL) or partial porto-caval shunt(PPCS) was done. SAL led to PVP reduction but not PVF reduction and PPCS also led to reduction of PVP, bilirubin, and ascites. Both led to better prognosis and reduction of medical costs due to ascites loss Impact of some reduction in graft regeneration and protein synthesis caused by PPCS is to be elucidated.(299 words)