老年患者肝移植的临床分析

Clinical analysis of liver transplantation in the aged patients

目的 探讨年龄≥60岁的老年患者肝移植的临床特点，总结临床诊治经验。方法 36例年龄≥60岁者接受肝移植治疗（老年组），术前其Child—Pugh评分为（7．86±2．06）分，其中34例采用非转流原位经典肝移植，2例为背驮式肝移植。术后采用他克莫司与糖皮质激素联用预防排斥反应，并辅以达利珠单抗诱导治疗。以同期施行肝移植、年龄小于60岁的214例患者作为对照。结果 老年组女性比例以及术前合并丙型肝炎、糖尿病的患者比例明显高于对照组，差异有统计学意义（P＜O．05，P〈0．05，P〈0．01），而合并乙型肝炎的患者比例则明显低于对照组（P〈0．01）。两组在手术方式、供肝缺血时间以及术中情况等方面的差异均无统计学意义。老年患者术后气管插管时间为（9．0±12．1）h，明显长于对照组的（5．8±6．8）h（P＜O．05），36．1％的患者术后插管超过12h，明显高于对照组的17．8％（P〈0．05）。老年组术后心血管并发症和细菌感染的发生率分别为13．9％和77．8％，明显高于对照组的1．9％（P〈0．01）和59．3％（P〈0．05），而急性排斥反应发生率为5．6％，明显低于对照组的19．6％（P〈0．05）。老年组患者术后1、2及3年存活率分别为77．8％、71．8％和61．6％，对照组分别为85．5％、72．2％和65．5％，两组间各存活率的差异均无统计学意义；老年组中超出米兰标准者肝移植后的1、2及3年存活率分别为56．3％、56．3％和36．5％，对照组分别为78．0％、62．8％和62．8％，两组比较，各存活率的差异均有统计学意义（P〈0．05）。老年组患者的死亡原因，肺部感染占第一位（41．7％），明显高于对照组的14．9％（P〈0．05）。结论 老年患者肝移植术后易并发感染和心血管疾病，肺部感染是老年患者术后死亡的主要原因；超出米兰标准的老年肝癌患者行肝移植需慎重。

Objective To investigate the features and treatment outcome of liver transplantation in patients over 60 years old. Methods From April 2001 to August 2005, 36 patients over 60 years old （senile group） and 214 patients under 60 years of age （control group） received liver transplantation in our liver transplantation unit. The Child-Pugh Score of the senile group was 7. 86±2. 06. Thirtyfour aged patients received standard orthotopic liver transplantation without bypass and the other two aged patients received piggyback liver transplantion. Postoperative immunosuppression was based on the combination of tacrolimus, hormone and daclizumab. The differences between the senile group and control group in preoperative, intraoperative and postoperative variables, including main clinical and laboratory features, were analyzed. Results The proportion of female and morbidity of hepatitis C and diabetes were higher in older liver transplant recipients （P〈0. 05, P〈0. 05, P〈0. 01）, while the morbidity of hepatitis B was lower than in control group （P〈0. 01）. There were no significant differences between two groups in the surgical techniques, ischemia duration of donor liver, or other intraoperative data （P〈0. 05）. The time of postoperative incubation in senile group was about （9. 0 ±12. 1） h, longer than in control group, which was about （5.8±6. 8）h （P〈0. 05）. Intubation duration over 12 h occurred in 36. 1% （13/36） of senile group and 17. 80/60 （38/214） of control group respectively （P〈0. 05 ）. The postoperative incidence of cardiovascular disease and infection was about 13. 9 0/60 and 77. 8 0/60 in senile group, while about 1.9 % （P〈0. 01） and 59. 3 0/60 （P〈0. 05） in control group, respectively. However, the incidence of acute rejection in senile group was 5. 60/60, lower than 19. 60/60 in control grouo （P〈0. 05）. The 1-, 2- and 3-year actuarial survival rate was 77. 80/60,71.8% and 61.6 % in senile group, and 85.5%,72. 2% and 65.5 % in control group, respectively （P〈0. 05）. In cases of liver carcinoma exceeding Milan criteria survival rate was markedly lower in senile group than in control group （1-, 2- and 3-year survival rate of 56. 3%, 56. 3% and 36. 5% in senile group and 78. 0%, 62. 8 % and 62. 8% in control group respectively, P〈0. 05）. The pulmo- nary infection was the most important cause of death in senile patients accounting for 41.7% and markly higher than 14. 9 % of control group （P〈0. 05）. Conclusion The postoperative incidence of cardiovascular disease and infection of senile group was higher and pulmonary infection was the most common cause of mortality in elderly liver recipients. Liver transplantation for the older patients with hepatocellular carcinoma over Milan criteria should be prudent.