心脏死亡器官捐献供体情况对受体肝脏移植术后终末期肝病模型评分影响研究
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摘要
背景近年来应用终末期肝病模型(MELD)评分探讨影响肝脏移植术后并发症发生率和病死率的高危因素成为热点,目前研究多集中于受体术前情况对术后恢复的影响。本研究通过研究供体术前情况对受体肝脏移植术后MELD评分变化的影响,为受体肝脏移植术后病情恢复提供新的思路。目的探讨心脏死亡器官捐献(DCD)供体术前情况对受体肝脏移植术后MELD评分的影响。方法回顾性选取2013年9月—2015年9月华中科技大学同济医学院附属同济医院器官移植研究所DCD肝脏移植供体25例,收集供体的性别、年龄、重症监护室(ICU)治疗时间、术前血清指标[丙氨酸氨基转移酶(ALT)、天冬氨酸氨基转移酶(AST)、直接胆红素(DBiL)、总胆红素(TBiL)、白细胞计数(WBC)及血红蛋白(Hb)]和受体肝脏移植术前、术后MELD评分,并进行相关性分析。结果男性供体19例、女性供体6例,受体肝脏移植术后MELD评分下降速度分别为(2.80±1.32)%和(1.40±0.66)%,差异有统计学意义(t=2.476,P=0.021);供体年龄<45岁15例,≥45岁10例,受体肝脏移植术后MELD评分下降速度分别为(2.73±1.26)%和(2.07±1.40)%,差异无统计学意义(t=-1.210,P=0.242);供体ICU治疗时间<5 d 3例,5～10 d 14例,>10 d 8例,受体肝脏移植术后MELD评分下降速度分别为(2.30±1.38)%、(2.85±0.85)%、(2.94±1.76)%,差异无统计学意义(F=0.957,P=0.516)。供体年龄、ICU治疗时间、术前AST、DBiL、WBC、Hb水平、受体肝脏移植术前MELD评分与受体肝脏移植术后MELD评分下降速度均无直线相关关系(r=-0.344,P=0.093;r=-0.294,P=0.154;r=-0.271,P=0.090;r=-0.181,P=0.386;r=-0.310,P=0.096;r=-0.205,P=0.325;r=-0.219,P=0.294)。供体术前ALT、TBiL水平与受体肝脏移植术后MELD评分下降速度呈负相关(r=-0.301,P=0.044;r=-0.372,P=0.012)。线性回归分析显示,供体术前ALT、AST、TBiL水平与受体肝脏移植术后MELD评分下降速度相关(P<0.05)。结论 DCD供体术前ALT、AST、TBiT水平越高,受体肝脏移植术后MELD评分下降速度越低,患者恢复越慢。DCD供体术前ALT、AST、TBiT水平是肝脏移植术后并发症发生的主要高危因素。
Background In recent years,the score of model for end-stage liver disease(MELD) which explores high-risk factors of the incidence of complication and mortality after liver transplantation has attracted a lot of attention. Most studies focus on the effect of preoperative conditions on postoperative recovery at present.In this study,we investigated the effect of preoperative conditions on the changes of MELD score after liver transplantation and provided new ideas for the recovery of recipients after transplantation.Objective To investigate the effects of the preoperative conditions of donors after cardiac death(DCD) on MELD scores after liver transplantation.Methods A total of 25 DCD liver transplantation cases in the Institute of Organ Transplantation,Tongji Hospital,Tongji Medical College,Huazhong University of Science and Technology were retrospectively selected from September 2013 to September 2015.Data on donor sex,age,duration of ICU treatment,preoperative serum indices [alanine aminotransferase(ALT),aspartate aminotransferase(AST),direct bilirubin(DBiL),total bilirubin(TBiL),white blood cell count(WBC),and hemoglobin(Hb) ],and the MELD scores of recipients before and after transplantation were collected and analyzed.Results The decreases in the postoperative MELD scores of male(n=19) and female(n=6) donors were(2.80±1.32)% and(1.40±0.66)%,and the difference was significant(t=2.476,P=0.021).There were 15 donors <45 years old and 10 donors ≥ 45 years old;the decreases in the postoperative MELD scores of the two groups were(2.73±1.26)% and(2.07±1.40)%,and were not significantly different between groups(t=-1.210,P=0.242).Regarding the duration of ICU treatment,there were 3 cases <5 d,14 cases 5-10 d and 8 cases >10 d;the decreases in the postoperative MELD scores of the three groups were( 2.30±1.38)%,(2.85±0.85)% and(2.94±1.76)%,and were not significantly different among groups(F=0.957,P=0.516).There was no linear correlation between the decreases in the postoperative MELD scores of the recipients and the age,duration of ICU treatment,preoperative AST,DBiL,WBC and Hb of the donors,as well as the preoperative MELD scores of the recipients(r=-0.344,P=0.093;r=-0.294,P=0.154; r=-0.271,P=0.090;r=-0.181,P=0.386;r=-0.310,P=0.096;r=-0.205,P=0.325;r=-0.219,P=0.294).The preoperative ALT and TBiL levels of the donors negatively correlated with the decreases in the postoperative MELD scores of the recipients(r=-0.301,P=0.044;r=-0.372,P=0.012).Linear regression analysis showed that the preoperative levels of ALT,AST and TBiL of the donors correlated with the decreases in the postoperative MELD scores of the recipients(P<0.05).Conclusion The higher levels of ALT,AST and TBiL before transplantation,the lower decreases in the postoperative MELD scores of recipients,and the slower recovery of recipients.A high level of ALT,AST or TBiL is the main risk factor for complications in liver transplantation.
Background In recent years,the score of model for end-stage liver disease(MELD) which explores high-risk factors of the incidence of complication and mortality after liver transplantation has attracted a lot of attention. Most studies focus on the effect of preoperative conditions on postoperative recovery at present.In this study,we investigated the effect of preoperative conditions on the changes of MELD score after liver transplantation and provided new ideas for the recovery of recipients after transplantation.Objective To investigate the effects of the preoperative conditions of donors after cardiac death(DCD) on MELD scores after liver transplantation.Methods A total of 25 DCD liver transplantation cases in the Institute of Organ Transplantation,Tongji Hospital,Tongji Medical College,Huazhong University of Science and Technology were retrospectively selected from September 2013 to September 2015.Data on donor sex,age,duration of ICU treatment,preoperative serum indices [alanine aminotransferase(ALT),aspartate aminotransferase(AST),direct bilirubin(DBiL),total bilirubin(TBiL),white blood cell count(WBC),and hemoglobin(Hb) ],and the MELD scores of recipients before and after transplantation were collected and analyzed.Results The decreases in the postoperative MELD scores of male(n=19) and female(n=6) donors were(2.80±1.32)% and(1.40±0.66)%,and the difference was significant(t=2.476,P=0.021).There were 15 donors <45 years old and 10 donors ≥ 45 years old;the decreases in the postoperative MELD scores of the two groups were(2.73±1.26)% and(2.07±1.40)%,and were not significantly different between groups(t=-1.210,P=0.242).Regarding the duration of ICU treatment,there were 3 cases <5 d,14 cases 5-10 d and 8 cases >10 d;the decreases in the postoperative MELD scores of the three groups were( 2.30±1.38)%,(2.85±0.85)% and(2.94±1.76)%,and were not significantly different among groups(F=0.957,P=0.516).There was no linear correlation between the decreases in the postoperative MELD scores of the recipients and the age,duration of ICU treatment,preoperative AST,DBiL,WBC and Hb of the donors,as well as the preoperative MELD scores of the recipients(r=-0.344,P=0.093;r=-0.294,P=0.154; r=-0.271,P=0.090;r=-0.181,P=0.386;r=-0.310,P=0.096;r=-0.205,P=0.325;r=-0.219,P=0.294).The preoperative ALT and TBiL levels of the donors negatively correlated with the decreases in the postoperative MELD scores of the recipients(r=-0.301,P=0.044;r=-0.372,P=0.012).Linear regression analysis showed that the preoperative levels of ALT,AST and TBiL of the donors correlated with the decreases in the postoperative MELD scores of the recipients(P<0.05).Conclusion The higher levels of ALT,AST and TBiL before transplantation,the lower decreases in the postoperative MELD scores of recipients,and the slower recovery of recipients.A high level of ALT,AST or TBiL is the main risk factor for complications in liver transplantation.
引文
[1]董权,李超,王胤佳,等.中国实行心脏死亡器官捐献供体的可行性分析[J].中国普外基础与临床杂志,2012,19(5):498-501.DONG Q,LI C,WANG Y J,et al.Feasibility analysis of organ donation after cardiac death in China[J].Chinese Journal of Bases and Clinics in General Surgery,2012,19(5):498-501.
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[4]中华医学会器官移植学分会,中华医学会外科学分会移植学组,中国医师协会器官移植医师分会.中国心脏死亡捐献器官评估与应用专家共识[J].中华移植杂志(电子版),2014,8(3):117-122.DOI:10.3877/cma.j.issn.1647-3903.2014.03.001.Chinese Society of Organ Transplantation,Section of Organ Transplantion,Chinese Society of Surgery,Chinese College of Transplant Doctors.Expert consensus on evaluation and application of organ donated after cardiac death in China[J].Chinese Journal of Transplantion(Electronic Edition),2014,8(8):117-122.DOI:10.3877/cma.j.issn.1647-3903.2014.03.001.
[5]GOK M A,ASHER J F,SHENTON B K,et al.Graft function after kidney transplantation from non-heartbeating donors according to maastricht category[J].J Urol,2004,172(6 Pt 1):2331-2334.DOI:10.1186/2110-5820-3-36.
[6]中华人民共和国卫生部医疗服务监管司.卫生部办公厅关于启动心脏死亡捐献器官移植试点工作的通知[EB/OL].(2011-05-03)[2017-06-24].http://www.moh.gov.cn/publicfiles/business/htmlfiles/zwgkzt/s9968/201104/51516.htm.
[7]LAUERER M,KAISER K,NAGEL E.Organ transplantation in the face of donor shortage-ethical implications with a focus on liver allocation[J].Visc Med,2016,32(4):278-285.DOI:10.1159/000446382.
[8]JADLOWIEC C C,TANER T.Liver transplantation:current status and challenges[J].World J Gastroenterol,2016,22(18):4438-4445.DOI:10.3748/wjg.v22.i18.4438.
[9]PARIKH N D,HUTTON D,MARRERO W,et al.Projections in donor organs available for liver transplantation in the United States:2014-2025[J].Liver Transpl,2015,21(6):855-863.DOI:10.1002/lt.24136.
[10]SCHLEGEL A,GRAF R,CLAVIEN P A,et al.Hypothermic oxygenated perfusion(HOPE)protects from biliary injury in a rodent model of DCD liver transplantation[J].J Hepatol,2013,59(5):984-991.DOI:10.1016/j.jhep.2013.06.022.
[11]SOTIROPOULOS G C,VERNADAKIS S,PAUL A,et al.Single-center experience on liver transplantation for model for endstage liver disease score 40 patients[J].Dig Dis Sci,2016,61(11):3346-3353.DOI:10.1007/s10620-016-4274-3.
[12]BHAT M,GHALI P,DUPONT B,et al.Proposal of a novel MELD exception point system for hepatocellular carcinoma based on tumor characteristics and dynamics[J].J Hepatol,2017,66(2):374-381.DOI:10.1016/j.jhep.2016.10.008.
[13]KAMATH P S,KIM W R.The model for end-stage liver disease(MELD)[J].Hepatology,2007,45(3):797-805.DOI:10.1002/hep.21563.
[14]DE PIETRI L,BIANCHINI M,ROMPIANESI G,et al.Thromboelastographic reference ranges for a cirrhotic patient population undergoing liver transplantation[J].World JTransplant,2016,6(3):583-593.DOI:10.5500/wjt.v6.i3.583.
[2]吴幼民,张升宁.中国器官捐献与分配相关问题初步探讨-法律是建立器官捐献与分配系统的基础,监管体系是法律实施的保障[J].中华移植杂志(电子版),2010,4(1):1-6.WU Y M,ZHANG S N.Preliminary discussion on organ donation and sharing in China:legislation is the foundation of the organ donation and sharing system,as well as a monitoring system to insure compliance with regulations[J].Chinese Journal of Transplantion(Electronic Edition),2010,4(1):1-6.
[3]李立.中国器官移植的现状与出路-心脏死亡器官捐献的标准与应用[J].中国普外基础与临床杂志,2012,19(5):464-467.LI L.Current situation and way out for solid organ transplantation in China-criteria and application of donor donation after cardiac death[J].Chinese Journal of Bases and Clinics in General Surgery,2012,19(5):464-467.
[4]中华医学会器官移植学分会,中华医学会外科学分会移植学组,中国医师协会器官移植医师分会.中国心脏死亡捐献器官评估与应用专家共识[J].中华移植杂志(电子版),2014,8(3):117-122.DOI:10.3877/cma.j.issn.1647-3903.2014.03.001.Chinese Society of Organ Transplantation,Section of Organ Transplantion,Chinese Society of Surgery,Chinese College of Transplant Doctors.Expert consensus on evaluation and application of organ donated after cardiac death in China[J].Chinese Journal of Transplantion(Electronic Edition),2014,8(8):117-122.DOI:10.3877/cma.j.issn.1647-3903.2014.03.001.
[5]GOK M A,ASHER J F,SHENTON B K,et al.Graft function after kidney transplantation from non-heartbeating donors according to maastricht category[J].J Urol,2004,172(6 Pt 1):2331-2334.DOI:10.1186/2110-5820-3-36.
[6]中华人民共和国卫生部医疗服务监管司.卫生部办公厅关于启动心脏死亡捐献器官移植试点工作的通知[EB/OL].(2011-05-03)[2017-06-24].http://www.moh.gov.cn/publicfiles/business/htmlfiles/zwgkzt/s9968/201104/51516.htm.
[7]LAUERER M,KAISER K,NAGEL E.Organ transplantation in the face of donor shortage-ethical implications with a focus on liver allocation[J].Visc Med,2016,32(4):278-285.DOI:10.1159/000446382.
[8]JADLOWIEC C C,TANER T.Liver transplantation:current status and challenges[J].World J Gastroenterol,2016,22(18):4438-4445.DOI:10.3748/wjg.v22.i18.4438.
[9]PARIKH N D,HUTTON D,MARRERO W,et al.Projections in donor organs available for liver transplantation in the United States:2014-2025[J].Liver Transpl,2015,21(6):855-863.DOI:10.1002/lt.24136.
[10]SCHLEGEL A,GRAF R,CLAVIEN P A,et al.Hypothermic oxygenated perfusion(HOPE)protects from biliary injury in a rodent model of DCD liver transplantation[J].J Hepatol,2013,59(5):984-991.DOI:10.1016/j.jhep.2013.06.022.
[11]SOTIROPOULOS G C,VERNADAKIS S,PAUL A,et al.Single-center experience on liver transplantation for model for endstage liver disease score 40 patients[J].Dig Dis Sci,2016,61(11):3346-3353.DOI:10.1007/s10620-016-4274-3.
[12]BHAT M,GHALI P,DUPONT B,et al.Proposal of a novel MELD exception point system for hepatocellular carcinoma based on tumor characteristics and dynamics[J].J Hepatol,2017,66(2):374-381.DOI:10.1016/j.jhep.2016.10.008.
[13]KAMATH P S,KIM W R.The model for end-stage liver disease(MELD)[J].Hepatology,2007,45(3):797-805.DOI:10.1002/hep.21563.
[14]DE PIETRI L,BIANCHINI M,ROMPIANESI G,et al.Thromboelastographic reference ranges for a cirrhotic patient population undergoing liver transplantation[J].World JTransplant,2016,6(3):583-593.DOI:10.5500/wjt.v6.i3.583.