胆红素对成人肝移植术后急性呼吸窘迫综合征的影响

The impact of bilirubin for acute respiratory distress syndrome in post-liver transplantation adults

目的：回顾性分析成人肝移植患者术后急性呼吸窘迫综合征（acute respiratory distress syndrome，ARDS）的发生和临床危险因素，探讨胆红素对ARDS发病和预后的影响。方法经医学伦理委员会同意，选择2004年1月1日至2011年12月31日的成人（年龄≥18岁）肝移植患者，所有数据来自加州大学洛杉矶分校（UCLA）的移植数据中心。诊断标准采用2011年ARDS柏林新定义，将患者分为ARDS组和非ARDS（No-ARDS）组两组，均采用全身麻醉。分析数据包括一般情况，实验室检查如总胆红素、肌酐、电解质（K+、Na+）及预后情况。数据分析软件采用IBM SPSS 20.0软件。结果1335例肝移植患者中有57例术后出现ARDS，发生率为4.3%；终末期肝病模型（MELD）评分和术前是否已经气管内插管两组之间差异均有统计学意义（均P＜0.05）。电解质和肌酐两组间无明显差异（P＞0.05）。总胆红素在术前〔（411.01±322.16）μmol/L比（250.17±271.04）μmol/L〕和术后第7天〔（164.84±146.55）μmol/L比（84.13±91.83）μmol/L〕ARDS组明显高于No-ARDS组（均P＜0.05）；经logistic分析，术前总胆红素≥324.9μmol/L（P＝0.013，95%CI＝1.164～3.578）和术后第7天总胆红素≥188.1μmol/L（P＝0.001，95%CI＝1.488～5.331）是ARDS发生的独立危险因素。ARDS组1年病死率明显高于No-ARDS组（6.10%比3.30%，P＝0.033）。结论①肝移植术后ARDS发生率为4.3%，是多个因素作用的结果；②胆红素对ARDS的作用与剂量有关，术前总胆红素≥324.9μmol/L、术后第7天总胆红素≥188.1μmol/L是术后ARDS发生的危险因素。

Objective To retrospectively analyze the incidence and risk factors of acute respiratory distress syndrome(ARDS)in post-liver transplant adult patients, and to approach the effect of bilirubin on morbidity and prognosis of ARDS. Methods After winning institutional review board approval, clinical data of adult patients(age≥18 years)undergone liver transplantation from UCLA Transplant Database Center between January 1st, 2004 and December 31st, 2011 were collected. Diagnosis of ARDS was determined using criteria proposed by the 2011 Berlin definition. All patients were underwent general anesthesia, and they were divided into ARDS group and non-ARDS group (No-ARDS). The general state and laboratory examination results including total bilirubin (TBil),creatinine (Cr),electrolyte (K+, Na+), and prognosis were analyzed. Statistical analyses were performed using the IBM SPSS 20.0. Results Of 1 335 patients undergone liver transplantation, 57 cases (4.3%)occurred postoperative ARDS. Univariate analysis showed ARDS was associated with significantly higher preoperative model for end-stage liver disease (MELD) score and requirement of endotracheal intubation(both P<0.05). TBil in the ARDS group were significantly higher than those in the No-ARDS group preoperatively〔(411.01±322.16)μmol/L vs.(250.17±271.04)μmol/L〕and the 7th day after liver transplantation〔(164.84±146.55)μmol/L vs.(84.13±91.83)μmol/L,both P<0.05〕. The Logistic analysis showed that TBil≥324.9 μmol/L ahead of liver transplantation(P=0.013, 95% CI=1.164-3.578) and TBIL≥188.1 μmol/L on the 7th day after liver transplantation(P=0.001, 95% CI=1.488-5.331)were independent risk factors for post transplant ARDS. One-year mortality in ARDS group was significantly higher than that in No-ARDS group(6.10% vs. 3.30%, P=0.033). Conclusion① ARDS occurred at a rate of 4.3% in adult patients and were associated with poor post transplant outcomes;②A higher concentration of bilirubin was associated with post-transplant ARDS. TBil≥324.9μmol/L ahead of liver transplantation and TBIL≥188.1μmol/L on the 7th day after liver transplantation were independent risk factors for post-transplant ARDS.