接受肝移植的晚期肝病患者高动力循环水平与MELD评分系统的临床研究

A clinical study on the evaluation by MELD scoring system and hyperdynamic circulation changes in end-stage liver diseases patients following liver transplantation

目的：探讨接受肝移植的晚期肝病患者MELD评分级别与其血流动力学高动力循环（HDC）水平的关系。方法针对146例接受肝移植的晚期肝病患者，术前抽血检查总胆红素（TBil）、血肌酐（Scre）、凝血酶原时间国际标准化比值（INR），以此计算 MELD 分值并进行分级（3级，Ⅰ 级≤10～15分，Ⅱ级15～25分，Ⅲ级≥25分）；另于手术开始前经肺动脉导管（Swan-Ganz导管）监测并记录HR、MAP、CO、CI、SVR、SVRI、MPAP、PAWP、PVR、LVSWI及RVSWI等指标；最后比较不同MELD分值级别与血流动力学变化的关系。结果 MELD 评分3个级别间CO分别是：（6.4±1.7）L/min，（8.5±2.0）L/min，（9.5±2.6）L/min；CI分别是：（3.7±1.1）L·min-1·m-2，（5.1±1.4）L·min-1·m-2，（5.4±1.4）L·min-1·m-2。SVR分别是：（978.9±260.5）dyn·s·cm-5，（653.7±254.1）dyn·s·cm-5，（594.4±204.2）dyn·s·cm-5；SVRI分别是：（1743.8±458.3） dyn·s·cm-5·m-2，（1126.1±478.1）dyn·s·cm-5·m-2，（1031.5±335.3） dyn·s·cm-5·m-2。其变化均有统计学差异（P＜0.01）；但两两比较仅MELD Ⅱ级和Ⅲ级组相对于I级有统计学差异（P＜0.01），而Ⅲ级与Ⅱ级组比较无统计学差异（P＞0.05）。HR、MAP、MPAP、PAWP、PVR、LVSWI及RVSWI等指标随MELD分值变化无统计学差异（P＞0.05）。结论晚期肝病患者HDC主要表现在高的心输出量和低的体循环血管阻力两个方面，即高的 CO＆CI 与低的 SVR＆SVRI，而且伴随肝功能MELD分值升高至15后，其血流动力学的HDC特征更明显，但代偿期肝硬化即便合并肝癌的患者HDC特征可能并不明显。

Objective To explore the relationship between the hyperdynamic circulatory characteristics and the different levels of MELD score in end-stage liver disease patients following liver transplantation. Methods The 146 end-stage liver disease patients following orthotopic liver transplantation（OLT） were examined and following results were obtained, including total bilirubin （TBil）, serum creatinine （Scre） and prothrombin time international normalized ratio （INR）, then calculated MELD score with them and divided into 3 groups according to the score （Ⅰ： ≤10-15, Ⅱ： 15-25, Ⅲ： ≥25）. Swan-Ganz catheter mornitoring was performed in those patients before OLT operation, heart rate （HR）, mean arterial pressure （MAP）, cardiac output （CO）, cardiac index （CI）, systemic vascular resistance （SVR）, systemic vascular resistance index （SVRI）, mean pulmonary arterial pressure （MPAP）, pulmonary capillary wedge pressure （PAWP） and pulmonary vascular resistance（PVR） were collected respectively. The hyperdynamic circulatory characteristics of different MELD score groups were analyzed. Results The CO＆CI of MELD Ⅰ, Ⅱ, and Ⅲ level groups was （6.4±1.7） L/min, （8.5±2.0） L/min, （9.5±2.6） L/min＆（3.7±1.1） L·min-1·m-2, （5.1±1.4） L·min-1·m-2, （5.4±1.4） L·min-1·m-2 respectively （P〈0.01）, and the SVR＆SVRI of MELD Ⅰ, Ⅱ, and Ⅲ level groups was （978.9±260.5） dyn·s·cm-5, （653.7±254.1） dyn·s·cm-5, （594.4±204.2） dyn·s·cm-5,（1743.8±458.3） dyn·s·cm-5·m-2, （1126.1±478.1） dyn·s·cm-5·m-2, （1031.5±335.3）·s·cm-5·m-2, （P〈0.01）. The SVR in patients of MELD 15 score（≥Ⅱ grade ） or more showed significant decrease, and meanwhile the CO significant increased. Although the MELD score＇s change, no significant difference with HR, MAP, MPAP, PAWP, PVR, LVSWI and RVSWI was observed （P〉0.05）. Conclusion The MELD score may exactly predict the severity of HDC. The HDC in end-stage liver disease patients was mainly manifested in two aspects of high cardiac output and low systemic vascular resistance, and with the higher MELD score, the more obvious hemodynamic characteristics of HDC. But for the compensated cirrhosis （MELD〈15 score ） even in patients with liver cancer the HDC feature was not obvious.