Nghien cmi Y hpc Y Hpc TP. Hd Chi Minh * Tap 18 * So 1 * 2014
24 HIEU QUA DIEU TRI IMMUNOGLOBULIN(PENTAGLOBIN) 6 BENH NHAN NHIEM TRUNG SAU MO GHEP GAN:
NHAN HAI TRUONG HQfP LAM SANG
Ngd Manh Dinh*, Nguyen Quoc Kinh*
Hai tnedng hap lam sdng nhiem triing ngng sau mo ghep gan dugc dieu tri tgi benh vien Viet Due. Trudng hgp 1: Nhiem triing dieang mat do soi mat/hep dudng mat sau mo'ghep gan thdng tliie22, c6 nhiem kliudn Ecoli ESBL, P.vulgaris ESBL vd Eiiia-ococcus faecalis. Ti-udng hgp 2 Viem phuc mgc sau mo ghep gan 5 nam vi kiman dtrobader freendii Ca hai trudng hgp diegc dmi tri nhiem triing. thuoc chdng thdi ghep kei hgp theo plidc do methylprednisolon vd hd trg immunoglobulin tinh mqch vd co hieu qud khi sir dung immunoglobulin debdo vi tqng ghep vd hd tro dieu tri nhiem triing.
ABSTRACT
EFFECTT^ TREATMENT IMMUNOGLOBUUN (PENTAGLOBIN) INPATIENTS WITH INFECTIONS AFTER LIVER TRANSPLANT SURGERY: CLINICAL CASES REPORTED
Ngo Manh Dinh, Nguyen Quoc Kinh
*YHocTP Ho Chi Minh* Vol. 18- No 1 - 2014:122 -126 Two cases of severe clinical infection after liva- transplant surgery treatmait in Vid Due hospitals, case 1:
biliary tiact inactions caused by gallstones / biliary atresia afier liver transplant surgery 22 moiiHis, with ESBL E.coli infections, ESBL P.vulgaris and Enterococcus faecalis. Case 2 postoperative peritoneal inflammation liver transplant 5 years baderium dtrobader fieaidii Both cases were treated infection, anti-rejection medication regimen combined methylprednisolone and intiavaious immunoglobulin and support to be effective when used to protect organ tiansplant immunoglobulin and supportive treatment of infections.
MO DAU Che pham hd tro miln djch (Pentaglobin) co r^-^ ^- I," 1.U-- 1.' - J- ' ij" chua Immunoglobulin (Ig) M, Ie A va Ie G chi Dieu tri chong mai ghep gan day co su tien Z 1°' ' ° ° _ bo Ion Iam ly le thai ghep cap giam to 60-75% ^ ^ " " " ^ •!«" « ho tro benh nhan nhiem de-n 40-50% va giam H, 10-15% ve 2% voi thai " " " ^ * « 'P''°' ' " ^ " ^ f " ? ^^^ " * " " " « "
ghep man tinh<™ Vile si, dung thuoc uc che ^^^ ^"^^""^ ^ " " * " " Irimg.cung ap miln dich chSng thai ghep thach thuc voi nguy ' ' ™ " ™ g l o b ^ * = b^^h nhan suy giam mien CO nhilm trimg, tang bien ehung sau mo va la •*'*• ^'^"^ ' " ""^S immunoglobin (ivig) co hieu
„s'„ , « ^u,-. „s' ^., 1,- xr u'- • • ' • ! , ' 1"3 tr^" benh nhan suy giam mien djch co van oe chu yeu sau ghep Nghien cuu giai phau ^ - -^ °
benh cua Torbenson M nguyen nhan gay tii " " ^ ^ '™"8 nangP^M. Benh vien Viel Dur gap vong do nhilm trimg chiem 64% Irong 321 benh ^ " " " " S ^'^ " " ™ ' ^ S "»"8 "^" ^ ^ 8™- nhan ghep li, 1982 den 1997, nhilm trimg do vi " ^ ^ ^ ^ ^ ^ * ™ 8 ' " ™ ° " ^^ ' * khuan 48%, virus 12% va nam 22%. Ti Ie nhilm ''^- ^ ^ " " ™ ' " ^ " 1"*. ™ ' * ^ " " ' '^'S & * m^ch trimg chiem 2/3 va hi 1-2,5 lan 6 benh nhan sau ' ' ° " " ''^,'* " ^ ""^"^ " " 8 ^ u ghep gan.
ghept^'. Dieu hi bien ehung nhiem bimg sau BENH AN LAM SANG ghep CO nhieu Ufe bp do thuoc khang sinh, Tmong hap thii 1 thuoc chongthaighepthehemoivabo sung cac 6 - f
che pham miln dich. Benh nhan (BN) Nguyen Phiic T, nam 67 hioi
* Khoa gay me hoi sire - BV Viet Diic Ha Noi
rrfc giri/icH Inc: Ths.BS. Ngo Manh Dinh DT 0987802889 Fmfl.;- manhdinh.ngo(5'j.mail com 122 Hpi Nghi Khoa Hpc Ky thu^t BV. Binh Dan 2014
Y Hpc TP. Ho Chi Minh * Tap 18 * So 1 * 2014 Nghien cuu Y hpc vao vi?n ngay 15/07/2013 ma so b?nh an 21723
voi ly do vang da sau mo ghep gan.
Tien suvd benh su
Viem gan B, xo gan mat bii, nhiem triing dudng mat tai phat nhieu lan, mo lay soi mat 1 Ian, mo ghep gan thang 11/2011 sau mo hep duong mat va duoc dait stent duong mat sau 6 thang. D^u tri iic che mien dich tacrolimus 0,5 mg X 4 vien/ ngay, ceilcept 250mg x 4 vien/ngay.
Duy tri nong do tacrolimus 4,6-5,9 ng/ml, tenofovir khang virus HBV. Duy tri insulin tinh m^ch dieu chinh duong mau 7-8 mmol/1.
Vao vien trong tinh trang tinh, cao 154cm nang 64kg, mach 75 lan/phiit, huyet ap 130/80mmHg co duy tri thuoc coveram Smg ngay 1 vien, nhi^t dp 36,7, vang da va niem mac, nuoc tieu vang dam. Khong xuat huyet dudi da, tim deu, phoi giam nhe thong khi day phoi, do chiic nang ho hap co thong khi han che nhe.
Byng mem khong chuong, ah dau tuc vung dudi suon phai, seo mo dudi suon hai ben.
Xet nghiem can ldm sdng
Sieu am gan: ong mat chii 9.2mm. Co hinh stent va soi kich thudc 13x9mm trong long ong mat chii. Chup MSCT: Soi gan trai, ohg gan ehung va ong mat chii. ong mat chii xoan van va hep, noi thong vdi stent, dau tren stent ap vao nhu mo gan.
Xet nghiem cong thuc mau: Hong cau 3,5 T/1; hemoglobin lllg/1; bach cau 3,67 G/l; tieu cau 69 G/I, nhom mau O Rh duong. Xet nghi?m dong mau va chuc nang gan:
Prothrombin 119%; INR 0,92; aPTT 33 giay;
GOT/GPT 151/152 U/1; GGT 609 U/1; albumin 36g/l; protein 76g/l; bilirubin TP/IT: 113/63,5 umol/1. Xet nghiem sinh hoa: Ure 6,2 mmol/l;
Creatinin 92umol/l; Glucose 7,3mmol/l; HBV DNA dudi nguong; HCV dudi nguong; CMV am tinh; nong dp tacrolimus 4,7ng/ml.
Cheat dodn
Nhilm trung dudng m§t do sdi mat/ hep dudng mat sau mo ghep gan thang thii 22, tieu dudng tang huyet ap.
Phdu thudt
Mo ong mat chii lay soi, bo stent duong mat npi soi duong mat trong mo, dan luu kehr. Sau mo duy tri huyet dong on dmh, thd may hd tro sau 3 gio nit npi khi quan. Cay djch mat co ket qua E.coli ESBL va P.vulgaris ESBL nhay vdi khang sinh dimg cho benh nhan tazodn, ciprinol, difflucan va tenofovir. Mach huyet ap on dinh, khong sot, dan luu kehr 250-300ml/24h.
Thudc uc che mien dich tacrolimus 0,5mg ngay 2 vien, ceilcept 250mg ngay 2 vien, duy tri nong do tir 2,9-4,7ng/ml. Cac thong so lam sang va chiic nang gan than dan binh thudng, dong mau va cac yeu danh gia viem on dinh. Tuy nhien sau 7 ngay phau thuat benh nhan sot, met moi, an uong kem. Yeu to viem va nhiem trimg tang dan, men gan tang. Cay dich mat ket qua Enterococais faecalis. Hpi chah quyet dinh doi khang sinh la meronem va amikacin, vancomycm dieu chinh theo chiic nang than, duy tri thuoc chong nam difflucan va thuoc chong virus tenofovir 200mg ngay 1 vien. Tang lieu thuoc iic che mien dich chong thai ghep. Cac thong so dien bieh theo bang 1.
Bdng 1: Dien bidi thong so'can ldm sdng trudc vd sau diing paitaglobin
Thoi diem
Than nhi#t B^ch cau CRP Procalcrtonin Prothrombin aPTT Y^u to V
SCOT SGPT GGT CO
Truwc dung
38,5 6,93 119 0,81 101 25,3 125,1 25 28 270 2,9
Ngay 1 38,5 8,04 117 1,90 111 29 123,2
31 25 279 8,4
Ngay 2 39 6,97 91,8 1,73 108 31,6 120 32 24 282 10,6
Ngay 3 37 14,98
75.5 1,19 101 27 112 31 22 188 13,3
Ngay 4 36,5 14,4 25,2 0,80 119 27,3 92,0 39 33 190 12,1
N g i y 5 37,0 12,5 16,7 0,41 96,4 26,8 78,9 45 46 478 12,0
Ngay 6 36,5 13,0 9,8 0,12 103,4 23,8 90,5 42 40 252 11,4
Dien bieh sau 5 ngay thay doi khang sinh, tang lieu thuoc chong thai ghep va ho trp thudc mien dich benh nhan het sdt, an uong ngon mieng va cac yeu to danh gia chiic nang dan binh thuong. Procalcitonin, CRP va bach cau giam d"an. Sau 15 ngay dieu tri benh nhan xuat \ien.
Hpi Nghi Khoa Hpc Ky thuat BV. Binh Dan 2014
Nghien ciru Y hpc Y Hpc TP. Ho Chi M i n h * Tap 18 * So 1 * 2014 Tnrcmg hpp thii 2
Benh nhan Pham N nam 58 tuoi vao vien ngay 8/7/2013 MSBA: 20872. Ly do dau byng di ngoai phan long.
Tien su vd benh su
Mo ghep gan do ung thu gan/ viem gan C nam 2008. Niit mach gan do ung thu gan tai phat each 3 nam, sau mit mach cat khdi gan hoai tir.
Dai thao dudng dang dieu tri insulin mixtard ngay 40UI, dudng huyet on dinh, tang huyet ap dieu tri vdi exforge 5/160mg va concor Smg ngay 1 vien, huyet ap duy tn tii 130-140/70-80 mmHg.
Thudc lie che mien dich tacrohmus Smg va certican Ipmg ngay 1 vien. Cach vao vien 2 tuan bfnh nhan dimg thuoc tacrolimus sang thuoc sirolimus 2mg/ngay nhung nong dp trung (Co) do trudc vao vien 5 ngay la 40ng/ml nen giam cdn Img sirolimus.
Tinh trang luc vdo
Benh nhan tinh, than nhif t 36,5 dp, mach 961/phut huyet ap 135/80mmHg. Bung mem ah dau khap biing, cam ling phuc mac, vo ni?u.
Xet nghiem HBV, HCV, CMV am tinh.
Chup CT-Scan vd sieu dm obung
Cd nhieu 6" gjam ty trpng tiong nhu mo gan ghep, kidl thudc to nhd khdng deu, nhieu dich 6 byng, it dich mang phoi hai ben.
Chan dodn
Viem phiic mac sau md ghep gan 5 nam/ cao huyet ap va dai thao dudng.
Td'tt thuong trong mo
Giiia cac Idp thanh bung cd nhieu dich mu, 6 bung cd khoang 500ml dich mau xanh due nhieu gia mac, gan cd 6 hoai tit 6cm, rupt non cd hai to chiic hoai hi nhung khong thiing, khau ep cam mau, khau Id thung rupt hoai tir.
Bfnh nhan dupe nit ong npi khi quan sau 12 gid. Giai phau benh: Viem mu va hoai tu to chiic thanh mac, hoai tir te bao gan chay mau, gan thoai hoa mo 20%. Cay djch d bung va thanh bung vi khu&i citrobacter freendii nhay
cam vdi khang sinh dang dung cho benh nhan la Meronem, amikacin, difflucan. Dien bien cac thong so theo bang 2.
Bdng 2: Dien biai can lain sdng trudc vd sau klii diing paitaglobin Idn 1
Thiy'i d i e m
Than nhiet Bach cau
C R P Procalcitonin Prothrombin aPTT Y l u to V
SGOT SGPT
T r u w c diJng 38,0 2,10 163 5,03 57,1 29,9 72,0 23 15
N g a y 1 38,5 3,56 165 5,6 77,5 27,5 70,5 38 2 5
N g a y 2 38,2 3,06 168 2,07 75,8 26.3 75,7 30 17
N g a y 3 38,5 3,33 117 0,98 64,3 2 5 84,4
98 39
N g a y 4 37.2 3.61 95 0,88 89,0 24,8 90,5 52 31
N g a y 5 36,8 3.39 72 0,57 92,0 25,1 82,3 58 38
Ng4y 6 36,5 4,01 47 0,44 84,9 23.8 89.2 62 41
Thudc chdng thai ghep duy tri tacrolimus D,5mg/24h. Sau dieu tri ho trp pentaglobin lan 1 cac thong so lam sang theo bang 1.2. Tuy nhien sau 5 ngay benh nhan met mdi, nhiem trimg tang, sot, sieu am gan cd cac 6 giam am khong ddng nhat. Chan doan nghi ngd ap xe gan chua loai trir thai ghep gan gap. Benh pham dich mang phdi va dich trong gan khong thay vi khuan. Hpi chan quyet dinh bo sung khang sinh vancomycin, cotistin va tang cudng lieu thudc tie che mien dich tacrolimus va methylprednisolon duy tri 250mg/24h lieu giam dan theo phac do, certican 0,5mg ngay 2 vien/24 gid. Ket qua theo bang 3.
Bang 3: Didi bidi can ldm sdng benh nhdn so 2 diing pentaglobin Bn thit 2
T 1 t 6 i d i i m
•Rian nhiet Bach cau CRP Procalcrtonin Prothrombin aPTT Yeu to V
SGOT SGPT GGT CO
Tnroc d i i n g
39,0 5,47 50,8 0,43 90,1 24,6 129 67 66 507 1,0
Ngay 1 38,8 6,38 67,2 0.71 82,6 25,1 125 123 88 447 1,2
Ngay 2 38,0 5,80 65.8 0,73 85.0 23.2 131 357 204 362 1,5
N g i y 3 36,7 5,67 56,7 0,65 84,4 23,0 123 259 235 378 2,9
Ngay 4 36,2 2,77 22,5 0,43 84,0 23,0 132 92 167 350 4,2
N g i y 5 36,0 4.93 11,4 0 2 9 96,4 24,2 115 40 107 362 4,5
Ngay 6 36,5 3.92 8.0 0.18 92,5 23,8 119 42 72 340 5,2
Ket qua sau 5 ngay benh nhan het sot, CRP va procaldtonin giam dan, cac yeu td danh gia
Hoi Nghi Khoa Hpc Ky thuat BV. Binh Dan 2014
Y Hpc TP. Hb Chi Minh * Tap 18 * Sd 1 * 2014 Nghien cmi Y hpc chiic nang gan dn dinh, ndng do thuoc thai
ghep giao dpng 4,2-5,2 ng/ml. Benh nhan xuat vien sau 15 ngay.
BAN LUAN
Nhiem khuan sau mo ghep gan
Nghien ciiu ciia Tsung-chia Chen 201Q^' thong ke 68 benh nhan tii 2004-2008 cho thay ti le nhiem trimg sau ghep la 40/68 b|nh nhan trong do vi khuah 38% virus 12% va nam 9%, Theo Forge Garbino tai Geneva nam 2005^' cho thay ti le nhiim tiiang gap d 78/98 BN tirong 228 Ian, nguyen nhan do vi khuan la 107 lan, 101 ^n do virus, 17 Ian do nam va 3 Ian do protozoan, chiem Ian lupt la 47%, 44%, 16%. Day la van de chu yeu va lam thoi gian song sau ghep giam xudng dang ke.
Tai Viet Diic, tien hanh ghep gan tu thang 11/2007, 16 ca ti-ong dd 3 BN lay gan tie ngudi song va 13 BN lay gan tii ngudi cho chet nao.
Hai trudng hpp tren nguyen nhan tir d nhiem khuan do hep duong mat sau dat stent cd sdi, vi khuah Escherichia coli va vi khuan Proteus vulgaris, enterococcus faecalis, cay mau cd nhiem Candida. Truong hop 2 nguyen nhan nhiem khuan la citrobacter feendii. Vi tri gay nhiem khuan tir thanh biing va o hoai tir tai gan va rupt. Nhieu nghien aiu cho thay nhiem khuan cd nguyen nhan tu vi khuah chiem ti le chti yeu sau ghep. Vi khuan hay gap Ian luot la Escherichia coli, Pseudomonas aeniginosa, staphylococcus aureus'^-^'"'. Ti le cao nhat nhiem khuah la sau 1 thang. Vi tri nhiem khuan ti le Tan lupt la: Vet md, phuc mgc, mau, dudng tie't nieu, dudng hd hap. Cac yeii to nguy co lam tang ti le nhiem trimg sau ghep la: co keo va ton thuong dudng mat, thdi gian nam vien lau...
Van de dieu tri thai ghep va nhiem trimg:
thai ghep bat dau tir 1-2 tuan dau vdi trieu chiing gpi y la sot dau mang sudn trai, giam sac to mat Nhung dau hieu nghi ngd la tang men gan va tang bilirubin. Cac xet nghiem deu cd dd nhay va dp dac hi?u khdng cao va de cd sir nham ISn thai ghep vdi cac benh ly nhu tac mat, giam
hoac mat chiic nang tang ghep, nhiem virus viem gan, CMV, ngo dpc tiiudc...nen giai phau benh la tieu chuan chinh de chan doan thai ghep.
Ddi vdi thai ghep man tinh thi tien lupng kha toi, thudng theo sau nhieu dot thai ghep cap tinh.
Hau qua cudi cung la mat chiic nang gan ghep va phai ghep gan mdi. Khi cd dau hieu tiiai ghep phac do dieu tii la phoi hpp vdi methylprednisolon vdi lieu lupng l,5-2mg/kg/24 gid. Vdi hai benh nhan tien ngoai tang lieu lupng tacrolimus va ceilcept phoi hpp vdi methylpredmsolon va bo sung them pentaglobin. Theo Jorge Garbino''' thay khac biet ve ti le nhiem trimg cd thai ghep 186/70 so vdi khdng CO bieii hien thai ghep la 42/42 benh nhan.
Ong thay cd tang nguy ca nhiem trimg tir vi khuan va nam khi dieu tri bang thuoc lie che mien dich va steroid Theo Rodrignez PM va csiio) (jJiu tri thai ghep cap tren 493 trudng hpp cho thay cd 48,1% dieu tri tacrolimus don thuan va 33,9% dieu tii phoi hop tacrolimus, thudc chdng chuyen hoa va steroid. Cdn lai 18% dieu tri hai loai thuoc hoac la steroid hoac chong chuyen hoa te bao vdi tacrolimus. Viec phdi hpp giiia tacrolimus va thuoc chdng chuyen hoa cung phii hpp vdi xu the hi^n nay de giam ti le suy than do thudc va nhiing bien chiing khac. Theo nhieu nghien ciiuC"! thi nong dp Co 7-10 ng/ml la phii hop de chdng thai ghep va giam nguy co nhiem trimg vdi nhung benh nhan cd nguy co cao va benh nhan cd nguy co thap duy tri lieu trung binh tir 3-7ng/ml. Viec kiem soat nong dp thudc lie che mien dich Iam giam nguy co tim maeh va benh ac tinh. Vdi trudng hpp lam sang dau tien benh nhan dupe dieu tri phoi hpp ea 3 loai tarcoHmus, ceilcept va steroid tiong do duy tri nong dp tir 8-12 ng/ml. Vdi benh nhan 2 b?nh nhan ciing duoc dieu tri phoi hpp ca 3 Ioai la tarcohmus, certican va steroid trong dd duy tri miic dn dinh Co mau la 5,2 ng/ml, day la benh nhan cd nguy eo thai ghep thap. Ca hai trudng hpp deu giam dupe sdt, chiie nang gan dn dinh, yeu td viem giam va deu giii nong dp Co on dinh khi ra vien.
Hpi Nghi Khoa Hoc Ky thuat BV. Binh Dan 2014 125
Nghien cmi Y hpc Y Hpc TP. Hd Chi Minh * Tap 18 * So 1 * 2014
Hieu qua ciia dieu tri imimoglobin ho tra duong tinh mach
Cdn nhieu tranh luan trpng viee chi dinh pentaglobin khi dieu tri benh nhan cd tinh trang nhiem trimg nang, dac biet tjenh nhan cd bieu hien suy giam mien dich. Tuy nhien cac nghien cihi cung dua ra nhung hieu qua dang ke bang viec thay doi lam sang va cac chi sd' viem nhu CRP va procalcitonin'^'. Ve mat thdi gian sdng sdt va tir vong do sdc nhiem trimg va nhiem trimg nang cung cd thay doi d lieu khuyen cao.
Theo Kevin B Laupland nghien cmi phan tich gpp cho thay cd su cai ttiien dang ke ve finh trang soc va ti Ie tir vong d benh nhan sdc nhiem trimg, tuy nhien cac nghien ciiu lam sang cd thiet ke khdng thuc su khach quan nen hi^u qua con ban cai. Theo khuyen eao ciia hiep hdi hoi sue cap ciiu hoa ky 2012 ve chi dinh ivIg tiong sdc nhiem trimg cdn han che va cdn tiiem nhieu nghien euu de khang dinh hi?u qua'-".
Trong 2 trudng hpp tren, b?nh nhan duoc dieu tri ivlg trong thdi gian 5 ngay vdi lieu luong khuyen cao la 0,4mg/kg/gid. Cd sy cai thien rd cac yeu to nhiem trimg va chiic nang tang ghep. Viec dieu ehinh khang khang sinh kiem soat nhiem trimg hpp Iy va dieu chinh nong dp thudc iic che mien dich phii hpp.
Theo John C Bucuvalas nam 2007^) nghien ciiu tren 1948 benh nhan sau ghep gan cd 336/1948 b^nh nhan dupe dieu tri ivlg trong 7 ngay, ket qua cho thay cd ti le thai ghep thap d benh nhan dieu tri la 31% so vdi 40% Dong thdi nguy co thai ghep lan 2-3 khi dieu tri ivlg thap hon so vdi nhdm khdng dupe dieu tri, vdi ti 1? la 13,1% so vdi 19,2%. Tac gia ciing danh gia la cd hieu qua trong viec bao ve chuc nang tang ghep. Tuy nhien van de gia thanh ciing la mpt yeu to can nhac khi dieu tri nhung d b^nh nhan ghep tang thi vi?c dieu tri va bao ve tang ghep la yeu to tien quyet. Theo Joseph Kahwaji cho thay diing ket hpp giiia ivlg vdi cac thuoc thai ghep d benh nhan sau ghep than khdng lam tang len nguy ca nhiim triing CO hpi. lordan SC eho thay dieu tri cd hieu qua
phdng ngira nhiem trimg sau ghep tang bao gom cytomegalovirus, parvovirus B19 va polyoma BK virus.
KET LUAN
Tir cac nghien ciiu lam sang va qua hai trudng hpp lam sang tren. Chiing tdi cho rSng ho trp ivlg la ed hieu qua trong viee hd trp dwu tri nhiem trimg va tang cuong viee bao v? tgng ghep. Tuy nhien viec sii dung ivlg dudng Snh mach d benh nhan nhiem trimg sau ghep tang can nghien ciiu them.
TAI LIEU THAM KHAO
I Barbier I . Garaa S, Cros J, et al (2013) Assessment of Chrwuc Rqection in Liver Graft Recipients Receiving Immunosuppression with low-Dose Caldneunn Inhibilois, / Hupatd 0168-8278.
' Bvicuvalas J C Anand R (2009) Treatment mth immunoglobuim imjjroves outcome for pediatne lu'er tTansplantreapients,LnwTraisp(.2009,15(11) 1564-9 3 C h e n T Q L i n P C C h i C Y , H o C M e t a l (2011) Intectionm liver
transplant recipients - Analysis ot 68 cases at teaching hospital in Taiwan, Jounuil of Microbiology, Immunohgv and bifichon.Vd 44, Issue 4,303-309
4. Dellinger P, et al (2012). Summing S^jsis Campaigi.
Internationa! Guidelines for Management of Severe Sepsis and Septic Shock. 2012,Cnlii:flI Care Medianr. 41; 2; 580-637, 5 Garbmo J, Romand J A Pittet D, et al (2005) Infection and
reiecbon in bver transplant patients, a 10-year Swiss angle- centre expenence. Swiss Med Wkly. 135(39-40)-587-93, 6 Jordan S C Toyoda M, Kahwaji J, Vo AA {2011) Clinical
aspects of mtra\'enous immunoglobulin use in solid organ transplantredpients^^m/riflnspfojil Feb;ll(2) 196-202, 7 Jordan S C Vo A A Peng A, Toyoda M, Tyan D (2006),
Intiavaious Gammaglobulin (IVIG)' A Novd Approach to Improve Transplant Rates and Outcomes m Highly HLA- SensitizedPatients. .4m/o^Trimsp;;6(3) 459-166.
8 Kusne S, Dummer JS, Smgh N, et al (1988), Infecticiis after liver transplantation. An analyas of 101 consecutive case, Medidne (Baltimore) Mar, 67(2)132-43,
9 U u p l a n d KB, KiApatrick AW, Ddaney A (2007) Pdydonal mtravenous immunoglobulin for the treatment of severe sepss and septic shock m cnhcally ill adults- a systematic review and meta-analysis. Cnl CareMed; 35(12) 26S6-92, 10 Rodriguez-Peralvarez M. Germani G, Papastergiou V, et al
(2013) Eariy tacrolimus exposure after liver transpJantaticm.
relahonship with moderate/severe acute rtTection and long- term crutcome / Hepatol; 58 (2): 262-70.
11 Romero FA and Razonahle KE (2011) Infections m liver transplant reapients. WoiM/HepjjIo/; 3(4) 83-92.
i z Torbenson M, Wang J, Nichols L. et al (1998), Causes of death in autopaed bver tian^lantation patients, Jan; 11(1) 37-4G Ngdy nhdn bdi bdo: 16/10/2013 Ngdy phdn bien nhdn xd bdibdo. 30/11/2013 Ngdy bdi bdo duac ddng: 20/02/2014
Hoi Nghi Khoa Hpc Ky thu?t BV. Binh Dan 2014
