重型肝炎肝移植术后早期持续性血液滤过的治疗价值

Continuous veno-venous hemofiltration in fulminant liver Failure in early post-transplant period

目的重型肝炎肝移植术后早期内环境和代谢紊乱会严重影响肝移植围手术期预后，本文旨在探索重型肝炎肝移植术后早期行持续性血液滤过对患者预后的影响。方法选取2013年10月至2015年2月在中山大学附属第三医院进行同种异体原位肝移植术的17例重型肝炎伴急性肝衰竭患者，患者无常规肾脏替代治疗的指征，术后48h内进行持续性静脉-静脉血液滤过治疗（CVVH），前瞻性观察其28d存活率，脓毒症、急性肾功能衰竭的发生率，重症监护病房（ICU）时间、术后清醒时间、气管切开或再插管率，对比2003年9月至2013年10月38例未在48h内给予CVVH的重型肝炎患者，比较上述指标差异。结果虽然早期CVVH并没有改善患者和移植物术后28d的存活率，但在肝性脑病Ⅲ期患者中，术后早期CVVH组的术后28d移植物存活率较高（P〈0．05）。术后早期CVVH同时能促进患者早清醒、缩短住ICU时间，减少感染、再插管或气管切开风险。结论重型肝炎肝移植术后早期CVVH能改善重症肝炎肝性脑病患者移植物的存活，减少受者感染等并发症的发生。

Objective Metabolic disturbance and systemic inflammatory response account for the early mortality of recipients with fulminant liver failure after liver transplantation. This study was designed to explore the roles of early continuous veno-venous hemofiltration （CVVH） in these patients. Method A total of 17 liver transplant recipients due to fulminant liver failure without any indication （Kidney Disease Improving Global Outcomes,KDIGO,2012） of renal replacement therapy from Oct. 2013 to Feb. 2015 were enrolled to initiate the CVVH in the Transplant Intensive Care Unit （TICU） of the 3rd Affiliated Hospital of Sun Yat-sen University during their 48 h post-transplant periods. Early survival （28 days） of recipients and grafts after transplantation, complications （sepsis, acute renal failer）, ICU stay, confusion duration and ventilation days, reintubation or tracheotomy were prospectively observed. Thirty-eight recipients matched by age and model for end-stage liver disease score were screened to be the control group from database （Sep. 2003 to Oct. 2013） of the hospital, by which the conventional therapy performed. Variables above were compared between groups. Result There was no significant difference in 28-day mortality of recipients and grafts between two groups. But in severe patients （grade III hepatoencephalopathy）, the 28-day survival rate in the grafts was higher than in the control group （P〈0. 05）. And CVVH group had shorter post--transplant ICU stay, ventilation days and confusion duration. Lower morbidity of sepsis and reintubation/tracheotomy rate were achieved by early CVVH. Conclusion Early CVVH after liver transplantation due to fulminant liver failure can improve graft survival and reduce risks of postoperative complications.