摘要
第一部分 经典原位肝移植术后早期急性肾功能不全的发生率和相关因素分析
目的
统计分析肝移植患者术后早期急性肾功能不全的发生率及相关因素，为临床防治肝移植围术期急性肾功能不全提供参考依据。
资料和方法
经典原位肝移植患者104例，其中62例术中不采用体外静脉-静脉转流技术，另42例术中采用体外静脉-静脉转流技术。以血清肌酐(serum creatine, sCr)＞1.5mg/dl作为诊断术后早期急性肾功能不全的标准。将采用和不采用体外静脉-静脉转流技术的两组患者术前、术中资料和术后早期急性肾功能不全的发生率进行分析。同时对不采用体外静脉-静脉转流技术的经典原位肝移植术后早期急性肾功能不全的相关因素进行分析。
结果
不采用体外静脉-静脉转流技术的A组62例患者中5例术前血清肌酐水平高于正常值，采用静脉-静脉转流技术的B组42例中4例术前血清肌酐水平高于正常，两组之间无显著性差异。两组患者术中血流动力学变化无显著差异。B组手术时间、门静脉、腔静脉阻断时间均高于A组；A组16例(25.8％)、B组11例(26.2％)术后早期血清肌酐水平高于正常值，两组之间差异无显著性。
不采用体外静脉-静脉转流技术经典原位肝移植术前血清肌酐水平、术中出血量、尿量等与术后早期肾功能损害密切相关，回归方程为y=-5.145-0.004*x_1+0.001*x_2+0.046*x_3，OR值分别为1.047，1.000，0.996；该方程对术后早期血清肌酐水平变异的预测正确率为93.5％。
浙江大学博士学位论文
结 论
1．本研究中，经典原位肝移植术后早期急性肾功能不全发生率为25．9％。
2．经典原位肝移植患者术前血清肌酌水平、术中出血量、尿量等可能是引起术后早期
血清肌配增高的主要因素。
3．肝移植患者术中不采用体外静脉－静脉转流技术并不增加术后早期急性肾功能不全
的发生率。
［关键词］肝移植；静脉－静脉转流；肾功能；危险性评估；因素分析
第二部分 经典原位肝移植无肝期对胃肠道和肾赃功能的
影响及东莫营碱的防治作用
目的
通过监测胃新膜pH、血浆内毒素水平、量、血清肌配水平等的变化，探讨不采用体外
静脉·静脉转流技术经典原位肝移植无肝期对胃肠道和肾脏功能的影响及东蓖若碱的防治
作用。
资料与方法
经典原位肝移植30例，随机分为两组：对照组和东莫著碱组，每组15例。东莫菩碱
组无肝期末和新肝早期给予东莫碧碱 0刀sing／kg加人 200ml生理盐水静滴。两组患者术中
均不采用体外静脉－静脉转流技术。术中监测血流动力学参数。用胃张力测定胃瓢膜pH，
观察并记录术前、rJ腔静脉阻断30分钟、门静脉开放5分钟、30分钟、90分钟和术毕的
血流动力学参数、胃肠道劾膜内PCOZ（PgCOZ）、胃肠道溢膜内PCOZ和呼气末PCOZ的压
力梯度（ngetco。）以及手术时间、门静脉阻断时间、出血量、输血输液量、尿量等，并
根据公式计算出 pHi。在相应时点采集动脉血，全自动生化仪测定血浆中 ALT、AST和 Cr；
ELISA法测定血浆中 TNF a、IL－lfl含量；TBA比色法测定血浆中 MDA含量；黄瞟吟氧
化法测定血浆中SOD含量；偶氮显色法鲨试验定量法测定血清中内毒素含量。酶免法测定
血清中pZ－微球蛋白。
结 果
1．两组患者年龄、体重、原发病、手术时间、门腔静脉阻断时间、出血量、输血输
液量等无明显差异，与对照组比较，东食碧碱组患者的尿量明显增多。
2．与术前值比较，fi静脉、下腔静脉阻断30分钟时两组MAP、CO、东蓖著碱组的
PCWP显著下降，HR、SVR明显增高，组间比较无差异。门静脉、下腔静脉开放5分钟，
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浙江大学博士学位论文
两组MAP明显下降，HR、PCWP显著增高，PCWP的增高以对照组更为明显。
3．pHi在门静脉、下腔静脉阻断30分钟、开放5分钟时两组均显著降低，组间比较
无差异；东莫碧碱组开放30分钟时pHi己明显纠正，开放90分钟已恢复正常；对照组pHi
纠正比东食著碱组慢，开放30分钟、开放90分钟时pHi明显低于东食碧碱组，手术结束
时对照组pHi恢复正常。与术前值比较，阻断30分钟、开放5分钟两组PgCO。明显升高，
但组间无差异；东蓖若碱组PgCO。在门静脉开放30分钟时恢复正常，对照组仍增高。两
组Pg七tCO。、Pg－aCO。在阻断30分钟、开放5分钟时显著增高，组间比较无差异。门静
脉开放30分钟时Pg－aCO。的变化与PgCO。相似。
4．两组患者中大部分出现外周血流中一过性内毒素水平升高。两组之间比较无显著
性差异。
结 论
1．经典原位肝移植无肝期门静脉、下腔静脉阻断后，胃励膜pHi明显低于正常、胃
鄙膜内存在酸中毒、PgCOZ、Pg－aCOZ显著增高。门静脉、下腔静脉开放后，胃劲膜pHi
Parti
The incidence and related risk factors of early acute renal dysfunction after
orthotopic liver transplantation
Objectives
To analyze the incidence and related risk factors of acute renal dysfunction early after orthotopic liver transplantation. It will be facilitated to prevention and treatment of eacute renal dysfunction after orthotopic liver transplantation.
Materials and methods
104 patients were included in this analysis. Veno-venous bypass was used in 42 patients ( group B ) and was not used in 62 patients(group A) .The diagnosis standard for early renal dysfunction is sCr>1.5mg/dl. The incidence of acute renal dysfunction early after OLT was compared between two groups. Meanwhile, the related risk factors of renal dysfunction early after operation without veno-venous bypass were analyzed with Logistic regression.
Results
There were 5 and 4 patients whose serum Cr before operation was up the normal level in group A and B , respectively. There was no significance between the two groups. There was no significance in hemodynamic parameters during the operation in two groups . The operation time, the clamping duration of portal vein and inferior vena cava in group B were longer than that of group A .There were 16 (25.8%) and 11 patients (26.2%) whose sCr early after operation were up
the normal level in group A and B, respectively,(p<0.05). The sCr before operation, the bleeding volume during the operation, and the urine output were significant risk factors responsible for the acute renal dysfunction early after orthotopic liver transplantation. OR value was 1.047 ,1.00, 0.99, respectively.
Conclusion
1. The incidence of acute renal dysfunction early after OLT was 25.9%.
2. Serum Cr before operation, bleeding volume and urine output during operation were significant risk factors responsible for acute renal dysfunction early after OLT.
3. OLT without veno-venous bypass in the operation would not increase the incidence of acute renal dysfunction early after OLT
[Key words] liver transplantation; veno-venous bypass; renal function; risk assessment; factor analysis
Part II
Effects of anhepatic phase of orthotopic liver transplantation(OLT) on the gastrointestinal and renal function and precaution and treatment of
scopolamine
Objectives
To evaluate the Effects of anhepatic phase of orthotopic liver transplantation(OLT) on the gastrointestinal and renal function and precaution and treatment of scopolamine
Materials and methods
30 patients undergoing OLT were randomly allocated to control group(group ns,n=15) and scopolamine group(Group s,n=15). For scopolamine group ,intravenous infusion of 200ml normal saline containing scopolamine O.OSmg/kgwere given 15min before unclamping of portal vein(PV) and early time of neohepatic period. The veno-venous bypass was not used in both groups. During the operation, hemodynamic parameters were monitored. The gastric mucosal Pco2(Pgco2), pH(pHi) was measured by balloon Tonometer. Hemodynamic parameters, Pgco2, pHi, gradient gap between gastric mucosal and arterial Pco2(Pg-aco2) at the time point of before operation(TO), 30min after clamping of PV(T1), 5min(T2), 30min(T3),90(T4)min after unclamping of PV, and the end of operation(TS) were recorded down and pHi was calculated by
6
formula of Henderson-Hasselbalch. Duration of operation, clamping time of PV, bleeding volume, infusion volume and urine output were also recorded down and the arterial samples were collected at the corresponding timepoints. Serum ALT,AST, and Cr were determined with an automatic biochemical analyzer. Blood MDA, SOD and P2-MG were determined by method of TBA, xanthine oxidase and enzyme-immune respectively. The endotoxin of artery was determined at the corresponding timepoints.
Results
1. No statistically significant differences were found in the underlying diseases, age, weights, duration of operation, clamping time of PV, infusion volume during the operation, et al, between two groups. Compared with Group ns, urine output were sign
引文
1. Lidofsky SD. Fulminant hepatic failure. Crit Care Med. 1995;11:415-430
2. Cabezuelo JB,Ramirez P, Acosta F, et al. Prognostic factors of early acute renal failure in liver transplantation. Transpl Proc. 2002; 34(1): 254-5
3. Colle I, Durand F, Pessione F et al. Clinical course, predictive factors and prognosis in patients with cirrhosis and type 1 hepatorenal syndrome treated with Terlipressin: a retrospective analysis. J Gastroenterol Hepatol. 2002 Aug; 17(8):882-8.
4．陈耿，董家鸿，何宇．肝移植术后急性肾功能衰竭的发生机理与对策，中华普通外科杂志，2002；17(4)：254
5. Haller M, Schonfelder R, Briegler J, et al. Renal function in the postoperative period after orthotopic liver transplantation. Transplant Proc 1992;24:2704-2706.
6. Wiesner RH, McDiarmid SV, Kamath PS, et al. MELD and PELD: application of survival models to liver allocation. Liver Transpl 2001 ;7:567-580.
7. Chertow GM, Lazarus JM, Christiansen CL, et al. Preoperative renal risk stratification. Circulation. 1997,95:878～884.
8. Baliga P, Merion RM, Turcotte JG, et al. Preopeative risk factor assessment in live transplantation. Surgery, 1992,112:704～711.
9. Nair S, Verma S, Thuluvath PJ. Pretransplant renal function predicts survival in patients undergoing orthotopic liver transplantation. Hepatology. 2002; 35(5): 1179-1185
10．钱叶本，陈规划，黄洁夫．肝移植患者术后早期死亡原因分析．中华器官移植杂志，2002，23 (3)：161～163．
11. Dixon BS, Anderson RJ. Nonoliguric acute renal failure. Am J Kidney Dis 1985;6:71-80.
12. Burchardi H, Kaczmarczyk G. The effect of anaesthesia on renal function. Eur J Anaesthesiol 1994 ;11(3):163-168.
13. Johnson MW, Powelson JA, Auchincloss H Jr et al. Selective use of veno-venous bypass in orthotopic liver transplantation. Clin Transplant 1996 Apr; 10(2): 181-5.
14. Corti A, Degasperi A, Colussi S et al. Evaluation of renal function during orthotopic liver transplantation Minerva Anestesiol 1997 Jul-Aug;63(7-8):221-8.
15. Gunning TC, Brown MR, Swygert TH et al. Perioperative renal function in patients undergoing orthotopic liver transplantation. A randomized trial of the effects of verapamil .Transplantation 1991 Feb;51 (2):422-7
16. Grande L, Rimola A, Cugat E et al. Effect of venovenous bypass on perioperative renal
function in liver transplantation: results of a randomized, controlled trial. Hepatology 1996 Jun;23(6): 1418-28.
17. Fan ST, Yong B.H, Lo CM, et al.Right lobe living donor liver transplantation with or without venovenous bypass. Br J Surg 2003, 90(1): 48-56
