肝移植治疗肝昏迷的围手术期管理经验探讨
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摘要
目的分析肝移植治疗肝昏迷受者的疗效并总结围手术期管理的临床经验。方法回顾性分析行肝移植治疗的22例肝昏迷患者的临床资料。观察受者的围手术期情况,包括手术时间、供肝热缺血时间、冷缺血时间、术中受体无肝期、术中出血量、术中输血量,术后早期血药浓度,术后并发症发生情况。对受者生存情况以及预后影响因素进行分析。结果 22例受者的手术时间为8(6～12)h,供肝热缺血时间为4(2～6)min,冷缺血时间为7(5～10)h,术中受体无肝期为80(55～120)min,术中出血量为1 139(400～4 000)mL,术中输血量为1 440(0～3 600)mL。受者术后1周左右他克莫司(FK506)血药浓度波动于6～11 ng/mL。术后6例受者死亡,死亡原因分别为原发性移植肝无功能1例、严重感染2例、脑出血引起严重脑水肿1例、多器官功能衰竭2例。肝昏迷受者移植术后1个月和1年的生存率为82%和77%。结论肝移植能够显著提高肝昏迷受者的生存率。术前降血氨、术后控制感染、改善肾功能以及根据免疫状态制定精准个体化免疫抑制方案是提高生存率的关键。
Objective To analyse the clinical efficacy of liver transplantation and summarize the clinical experience of perioperative management in patients with hepatic coma. Methods Clinical data of 22 patients with hepatic coma undergoing liver transplantation were retrospectively analyzed. The perioperative conditions of the recipients were observed, including operation time, warm/cold ischemia time of donor liver, intraoperative anhepatic phase of the recipients, intraoperative blood loss, intraoperative blood transfusion, early postoperative blood drug concentration and incidence of postoperative complications. The survival situation of the recipients and the influencing factors of clinical prognosis were analyzed. Results The operation time of 22 recipients was 8(6-12) h, the warm ischemia time of donor liver was 4(2-6) min, the cold ischemia time was 7(5-10) h, intraoperative anhepatic phase of recipients was 80(55-120) min, intraoperative blood loss was 1 139(400-4 000) mL and intraoperative blood transfusion was 1 440(0-3 600) mL.The blood concentration of tacrolimus(FK506) fluctuated between 6 and 11 ng/mL at postoperative one week.Six recipients died after liver transplantation including 1 case of primary graft liver failure, 2 cases of severe infection,1 case of severe cerebral edema caused by cerebral hemorrhage and 2 cases of multiple organ failure. The postoperative1 month and 1 year survival rates of hepatic coma recipients were 82% and 77%. Conclusions Liver transplantation can significantly improve the survival rate of patients with hepatic coma. Preoperative decreasing blood ammonia, controlling postoperative infection, improving renal function and formulating precise individualized immunosuppression therapy according to immune status play a pivotal role in enhancing the survival rate.
Objective To analyse the clinical efficacy of liver transplantation and summarize the clinical experience of perioperative management in patients with hepatic coma. Methods Clinical data of 22 patients with hepatic coma undergoing liver transplantation were retrospectively analyzed. The perioperative conditions of the recipients were observed, including operation time, warm/cold ischemia time of donor liver, intraoperative anhepatic phase of the recipients, intraoperative blood loss, intraoperative blood transfusion, early postoperative blood drug concentration and incidence of postoperative complications. The survival situation of the recipients and the influencing factors of clinical prognosis were analyzed. Results The operation time of 22 recipients was 8(6-12) h, the warm ischemia time of donor liver was 4(2-6) min, the cold ischemia time was 7(5-10) h, intraoperative anhepatic phase of recipients was 80(55-120) min, intraoperative blood loss was 1 139(400-4 000) mL and intraoperative blood transfusion was 1 440(0-3 600) mL.The blood concentration of tacrolimus(FK506) fluctuated between 6 and 11 ng/mL at postoperative one week.Six recipients died after liver transplantation including 1 case of primary graft liver failure, 2 cases of severe infection,1 case of severe cerebral edema caused by cerebral hemorrhage and 2 cases of multiple organ failure. The postoperative1 month and 1 year survival rates of hepatic coma recipients were 82% and 77%. Conclusions Liver transplantation can significantly improve the survival rate of patients with hepatic coma. Preoperative decreasing blood ammonia, controlling postoperative infection, improving renal function and formulating precise individualized immunosuppression therapy according to immune status play a pivotal role in enhancing the survival rate.
引文
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[2]王丰姣,柳明江,吴瑞红,等.肝性脑病患者短期预后的相关危险因素分析[J].临床肝胆病杂志,2017,33(4):711-714.DOI:10.3969/j.issn.1001-5256.2017.04.022.WANG FJ,LIU MJ,WU RH,et al.A multivariate logistic regression analysis of short-term prognosis of patients with hepatic encephalopathy[J].J Clin Hepatol,2017,33(4):711-714DOI:10.3969/j.issn.1001-5256.2017.04.022.
[3]LEISE MD,POTERUCHA JJ,KAMATH PS,et al.Management of hepatic encephalopathy in the hospital[J].Mayo Clin Proc,2014,89(2):241-253.DOI:10.1016/j.mayocp.2013.11.009.
[4]HASSANEIN T.Current state of knowledge of hepatic encephalopathy(part IV):management of hepatic encephalopathy by liver support systems[J].Metab Brain Dis,2017,32(2):303-306.DOI:10.1007/s11011-016-9911-1.
[5]KODALI S,MCGUIRE BM.Diagnosis and management of hepatic encephalopathy in fulminant hepatic failure[J]Clin Liver Dis,2015,19(3):565-576.DOI:10.1016/j.cld.2015.04.006.
[6]O'GRADY J.Liver transplantation for acute liver failure[J].Best Pract Res Clin Gastroenterol,201226(1):27-33.DOI:10.1016/j.bpg.2012.01.012.
[7]OLSON JC.Acute-on-chronic liver failure:management and prognosis[J].Curr Opin Crit Care,2019,25(2):165-170.DOI:10.1097/MCC.0000000000000595.
[8]WEISSENBORN K.Minimal/covert hepatic encephalopathyimpact of comorbid conditions[J].J Clin Exp Hepatol,20199(1):109-111.DOI:10.1016/j.jceh.2018.08.010.
[9]DEMETRIOU AA,BROWN RS JR,BUSUTTIL RW,et al.Prospective,randomized,multicenter,controlled trial of a bioartificial liver in treating acute liver failure[J]Ann Surg,2004,239(5):660-670.
[10]KARVELLAS CJ,TODD STRAVITZ R,BATTENHOUSEH,et al.Therapeutic hypothermia in acute liver failure:a multicenter retrospective cohort analysis[J].Liver Transpl2015,21(1):4-12.DOI:10.1002/lt.24021.
[11]WONG RJ,AGUILAR M,GISH RG,et al.The impact of pretransplant hepatic encephalopathy on survival following liver transplantation[J].Liver Transpl,201521(7):873-880.DOI:10.1002/lt.24153.
[12]李海波,符洪源,陆桐宇,等.肝移植领域2017年度重要进展盘点[J].器官移植,2018,9(1):41-50,82.DOI:10.3969/j.issn.1674-7445.2018.01.006.LI HB,FU HY,LU TY,et al.Summary of important research on liver transplantation in 2017[J].Organ Transplant,2018,9(1):41-50,82.DOI:10.3969/j.issn.1674-7445.2018.01.006.
[13]邓小红,张倩倩,蔡燕,等.肝癌患者肝移植前外周血免疫表型分析[J].中山大学学报(医学科学版),201839(2):178-185,226.DENG XH,ZHANG QQ,CAI Y,et al.Detection of immune cell subsets of peripheral blood in hepatocellular carcinoma before liver transplantation[J].J Sun Yat-sen Univ(Med Sci),2018,39(2):178-185,226.
[14]MURALI AR,CHANDRA S,STEWART Z,et al.Graft versus host disease after liver transplantation in adults:a case series,review of literature,and an approach to management[J].Transplantation,2016,100(12):2661-2670.
[15]CHENG CN,LIN SW,WU CC.Early linezolidassociated lactic acidosis in a patient with Child's class Cliver cirrhosis and end stage renal disease[J].J Infect Chemother,2018,24(10):841-844.DOI:10.1016/j.jiac.2018.02.002.
[16]BAEK SD,JANG M,KIM W,et al.Benefits of intraoperative continuous renal replacement therapy during liver transplantation in patients with renal dysfunction[J].Transplant Proc,2017,49(6):1344-1350DOI:10.1016/j.transproceed.2017.03.094.
[17]PANTHAM G,POST A,VENKAT D,et al.A new look at precipitants of overt hepatic encephalopathy in cirrhosis[J].Dig Dis Sci,2017,62(8):2166-2173.DOI:10.1007/s10620-017-4630-y.
[18]LEE SM,SON YK,KIM SE,et al.Clinical outcomes of peritoneal dialysis in end-stage renal disease patients with liver cirrhosis:a propensity score matching study[J].Perit Dial Int,2017,37(3):314-320.DOI:10.3747/pdi.2016.00129.
[19]WAGHRAY A,WAGHRAY N,KANNA S,et al.Optimal treatment of hepatic encephalopathy[J].Minerva Gastroenterol Dietol,2014,60(1):55-70.
[20]SHAW J,BAJAJ JS.Covert hepatic encephalopathy:can my patient drive?[J].J Clin Gastroenterol,201751(2):118-126.DOI:10.1097/MCG.0000000000000764.
[21]BRESCIA MD,MASSAROLLO PC,IMAKUMA ESet al.Prospective randomized trial comparing hepatic venous outflow and renal function after conventional versus piggyback liver transplantation[J].PLo S One,2015,10(6):e0129923.DOI:10.1371/journal.pone.0129923.