A 43-year-old man was detected positive for hepatitis B surface antigen in 1994, but was not followed-up regularly. From October 2004, progressive weight loss and decreased urine output was noted and the patient was admitted to the hospital on November 20, 2004. By January 2005, patient's body weight reduced by 15 kg, and preoperative body mass was 60.5 kg. Physical examination identified discomfort in the right upper abdomen and abdominal distension. Laboratory examination was as follows. Blood routine: white blood cells (WBC) 7.2 x 109/L, red blood cells (RBC) 3.4 x 1012/L, Hb 6 g/L, PLT 70 x 1012/L. Urine routine: protein +++, occult blood ++. Liver function: alanine aminotransferase (ALT) 117 U/L, aspartate aminotransferase (AST) 113 U/L, total protein (TP) 50 g/L, albumin (ALB) 26.9 g/L, alkaline phosphatase (ALP) 99 U/L, gamma-glutamyltranspeptidase (GGT) 109 U/L, total bilirubin (TBIL) 102 mumol/L. Renal function: blood urea nitrogen (BUN) 23.6 mmol/L, creatinine (CRE) 664 mumol / L. Hepatitis B series tips: hepatitis B surface antigen (HBsAg), hepatitis B e antibody (HBeAb), hepatitis B core antibody (anti-HBC) positive, HBV-DNA 1.5 x 107/ml. Ascites was yellow turbid with RBC 2,200 x 106/ml, WBC 50 x 106/ml, GLU 9.5 mmol/L, TP 9 g/L, ALB 6.0 g/L. Fasting and postprandial blood sugar were 10.8 and 18.4 mmol/L, respectively. Ultrasonography showed cirrhosis, a large amount of ascites, splenomegaly, large pancreatic head, and expansion of the main pancreatic duct. CT examination showed cirrhosis, ascites, portal hypertension, cholecystitis, atrophy of the pancreatic body and tail, significant expansion of the pancreatic duct, full pancreatic head, and atrophy of both kidneys. Magnetic resonance imaging showed cirrhosis with moderate ascites, obvious pancreatic duct dilatation, bilateral kidney atrophy, and cholecystitis. Renal dynamic imaging showed severe damage to both kidneys. The non-functional left and right renal glomerular filtration rate (GFR) were ~3.73 ml/min/1.73 m2 and 5.46 ml/min/1.73 m2, respectively. The patient was diagnosed with post-hepatitis B cirrhosis, hepatic insufficiency with chronic renal insufficiency and chronic pancreatitis leading to insulin-dependent diabetes mellitus (IDDM). A simultaneous liver-pancreas-kidney transplantation surgery was planned.
The recipient blood type was type B, Rh+. The donor blood types were O-type and B-type. The panel reactive antibody (PRA) was negative for the recipient. The human leukocyte antigen (HLA) sites of the donors and recipient are shown in Table 1. Both pre-transplant lymphotoxicity tests were negative.
In the initial operation, the organs were obtained from donor 1 and trimmed using routine methods, and transplanted in the order of liver, kidney, and pancreas. Under general anesthesia, an incision under the bilateral costal margin was made, and a piggyback orthotopic liver transplantation was performed. Further, a conventional kidney transplantation was performed in the left axilla, and the pancreas was implanted into the right axilla. Carrel cuff of the abdominal aorta with superior mesenteric artery and celiac trunk were anastomosed end-to-side with external iliac artery, and portal vein of the transplant pancreas was anastomosed end-to-side with external iliac vein. The donor pancreaticoduodenal segment was anastomosed laterally with the upper jejunum. After anastomosis, the venous and arterial blood supply was opened, the drainage tube was placed, and the incision was sutured (Figure 1).
Following the operation, the liver and kidney function, blood and urine bilirubin, blood sugar, blood and urine routine, blood coagulation, D-dimer, serum C-peptide, blood and urine amylase, tacrolimus (FK506) blood concentration and immune index were monitored. Two doses of basiliximab were used to induction therapy. Three days after operation, acute rejection was considered and rabbit anti-human thymocyte immunoglobulin (ATG) was added, 100 mg/d for 7 days. The immunosuppressive regimen was FK506+ mycophenolate mofetil (MMF) + prednisone acetate (Pred).
One week after operation, ALT 57U/L, AST 43 U/L, ALB 36.9 g/L, TBIL 22 mumol/L, BU 26.5 mmol/L, CRE 683 mumol/L were re-examined. Insulin was completely discontinued. Continuous renal replacement therapy maintained a stable internal environment and blood and urine amylase were normal. Ultrasonography showed that the blood flow of the transplanted hepatic artery, portal vein, inferior vena cava, common bile duct, and pancreatic artery and vein was normal.
On the 16th day after operation, B-mode ultrasonography revealed that the blood flow perfusion of the transplanted kidney decreased significantly, the resistance index of the segmental artery blood flow increased to 1, 24 h urine volume was <300 ml, and PRA was negative. The patient was diagnosed with acute rejection of transplanted kidney. The original transplanted kidney was excised under general anesthesia and a second kidney transplantation (obtained from donor 2) was performed at the original transplanted site 16 days later after diagnosis of rejection of the first kidney. The pathological diagnosis of the original transplanted kidney was acute rejection. The first 24 h urine volume was 7,000 ml after the second operation. On the third day, renal function was reviewed: BUN 6.5 mmol/L, CRE155 mumol/L. One week after the second operation, the patient peripheral blood WBC was 2.1 x 109/L, RBC 1.4 x 1012/L, Hb 5.2 g/L, PLT 6 x 1012/L, PT 52 s, APTT 120 s, fibrinogen 1.2 g. Surgical wounds continued to ooze blood. Considering the occurrence of bone marrow suppression, MMF was discontinued and immunosuppressive therapy was maintained by FK506 + Pred regimen. The patient was hospitalized for 33 days and discharged after the function of the transplanted liver, kidney, and pancreas was stable.
One month after the operation, the patient returned to a normal diet and resumed social work 3 months later. The patient was regularly monitored for blood routine, liver function, kidney function, eGFR, electrolytes, blood sugar, blood lipids, hepatitis B virus DNA quantification and FK506 blood trough concentration. CT and ultrasound were routinely performed and medication was accordingly adjusted. No clinically visible rejection occurred after the second operation. Hepatitis B check was negative except for positive HBsAb. No other drugs were used except oral immunosuppressive agents, anti-hepatitis B immunoglobulin and lamivudine treatment. By June 2013, physical examination showed that the patient's body weight was 73 kg. Blood routine: WBC 7.6 x 109/L, RBC 4.4 x 1012/L, Hb 11.8 g/L, PLT 110 x 1012/L. Urine protein and occult blood were negative. Liver function: ALT 20 U/L, AST 19 U/L, TP 62 g/L, ALB 42 g/L, ALP 39 U/L, GGT 38 U/L, TBIL 19 mumol/L. Renal function: BUN 6.5 mmol/L, CRE 130 mumol/L, and blood uric acid 399 mumol/L. Fasting blood glucose was 4.3 mmol/L, postprandial blood glucose was 10.3 mmol/L, and HBV-DNA was <1,000/ml. The amount of FK506 was 1.5 mg twice daily, and the trough concentration was 3.0-4.5 ng/ml. The CT and ultrasound showed that the transplanted liver was in situ, the left lobe anterior and posterior diameter was 5.4 cm, and the upper and lower diameter was 3.4 cm, the right lobe anterior and posterior diameter was 11.5 cm, and the upper and lower diameter was 11.5 cm. The morphology was regular, the echo was moderately dense, and the distribution was uniform. The right hepatic artery blood flow velocity Vmax = 55.1 cm/s, RI = 0.71, CDFI showed the color blood flow was well filled. The inner diameter of the portal vein was 0.9 cm, and the blood flow velocity Vmean = 17 cm/s. CDFI showed that the color blood flow was well filled. The inner diameter of the hepatic vein was normal. The transplanted pancreas was located in the right iliac fossa, with a size of 2.7 cm at the head, 1.4 cm at the body, and 2.2 cm at the tail. The echo is moderately dense and evenly distributed. A color blood flow signal can be seen inside. The transplanted kidney was located in the left axilla, the size was 11.8 x 5.3 x 5.3 cm, the boundary was clear, the echo in the parenchyma was dull, the renal pelvis and renal pelvis were separated, and the inner part was a liquid dark area. The maximum anteroposterior diameter was 0.7 cm. The blood flow velocity in the transplanted renal cortex was measured as Vmax = 89.2 cm/s, RI = 0.63. CDFI showed that the color flow was well filled.