血浆置换联合持续血液透析滤过治疗小儿急性肝功能衰竭的临床疗效观察

Clinical application of plasma exchange combined with continuous veno-venous hemodialysis filtration in children with acute liver failure

目的 探讨血浆置换（plasma exchange,PE）联合持续静静脉血液透析滤过（continuous veno-venous hemodialysis filtration,CVVHDF）治疗儿童急性肝功能衰竭（acute liver failure,ALE）的应用价值.方法 中国医科大学附属盛京医院PICU 2008年8月至2014年1月收治39例符合ALF诊断患儿,行PE联合CVVHDF治疗,治疗方法为PE后立即进行CVVHDF,每次PE＋ CVVHDF历时24～72h,治疗前后采集患儿凝血酶原时间、血氨、谷丙转氨酶、谷草转氨酶、血氨总胆红素、直接胆红素等指标,并对35例存在肝性脑病患儿治疗前后进行Glasgow昏迷评分.结果 39例患几经PE＋ CVVHDF治疗后20例ALF患儿（51.3％）肝功能恢复正常出院,7例治疗过程中死亡,12例因个人原因治疗过程中放弃治疗,后电话随访死亡.经PE＋ CVVHDF治疗后,患儿总胆红素、直接胆红素、谷丙转氨酶、谷草转氨酶分别较治疗前下降[（128.8 ±82.6） μmol/L vs （73.2±92.4） μmol/L;（90.2±71.5）μmol/L vs （55.1±42.6）μmol/L;（3 024.1±2457.0）U/L vs（1 256.8 ±757.8）U/L;（3 420.6±2216.3）U/L vs （579.4±338.6）U/L] （P ＜0.05）;治疗后凝血酶原时间较治疗前缩短[（40.4±23.0）s vs（22.8±9.4）s]（P＜0.0l）,临床出血倾向明显减轻;Glasgow昏迷评分明显升高[（9.5±3.1）分vs （12.1±2.9）分]（P＜0.01）.结论 PE联合CVVHDF治疗小儿ALF可明显改善临床症状及生化指标,安全性好,无明显不良反应.

Objective To observe the clinical effect of plasma exchange（PE） combined with continuous veno-venous hemodialysis filtration（CVVHDF） in children with acute liver failure.Methods Thirty-nine cases with acute liver failure admitted to pediatric intensive care unit of Shengjing Hospital Affiliated to China Medical University from August 2008 to January 2014 were treated with PE combined with CVVHDF.CVVHDF was performed after PE immediately,each PE ＋ CVVHDF lasted 24 ～ 72 hours.Prothrombin time,blood ammonia,alanine transaminase,aspartate transaminase,serum total bilirubin,conjugated bilirubin were detected before and after PE ＋ CVVHDF treatment.Glasgow Coma Scale were assessed before and after PE ＋CVVHDF in the thirty-five cases with hepatic encephalopathy.Results After the treatment of PE ＋ CVVHDF,20 children were clinical recover,7 died,12 abandoned the treatment and the results of follow-up were death.PE ＋ CVVHDF was effective in the treatment by decreasing serum total bilirubin,conjugated bilirubin,alanine transaminase,aspartate transaminase [（128.8 ± 82.6） μmol/L vs （73.2 ± 92.4） μmol/L; （90.2 ±71.5） μmol/L vs （55.1 ± 42.6） μmol/L; （3 024.1 ± 2 457.0） U/L vs （1 256.8 ± 757.8） U/L; （3 420.6 ±2 216.3） U/L v s （579.4 ± 338.6） U/L] （P ＜ 0.05）,increasing Glasgow Coma Scale （9.5 ± 3.1 vs 12.1 ±2.9） （P ＜0.01）,shortening prothrombin time[（40.4 ± 23.0） s vs （22.8 ±9.4） s] （P ＜0.01）,in association with the improvement of hemorrhage tendency.Conclusion PE ＋ CVVHDF significantly improves clinical symptoms and biochemical abnormalities in children with acute liver failure.Security of PE ＋ CVVHDF is good and with no obvious adverse reactions.