肝移植术后早期血清球蛋白水平的变化规律及其临床意义

Early dynamic changes of serum globulin and its clinical significance after liver transplantation

目的探讨肝移植术后早期血清球蛋白水平的变化规律及其降低的危险因素,并分析球蛋白降低对受者术后短期急性排斥反应(acute rejection,AR)发生及预后的影响。方法随访收集天津市第一中心医院2011年1月-12月170例接受尸体全肝移植手术受者资料,以患者术后第1天较术前球蛋白降低值D的中位值作为截点,其中85例患者为D≥10.5 g/L,85例为D<10.5 g/L。采用回顾性研究,收集受者基本信息、手术资料及术后AR发生及生存状况,并对受者肝移植术后球蛋白降低的危险因素进行分析及术后1、3年累计生存率进行对比分析。结果与术前血清球蛋白水平相比,肝移植术后第1天,两组受者血清球蛋白显著降低,随后逐日增高,两组术后第1天球蛋白水平D<10.5 g/L组低于D≥10.5 g/L组,差异有统计学意义(P<0.05),其他时间点无统计学差异(P>0.05)。与D<10.5 g/L组相比,D≥10.5 g/L组受者体重较低〔体重(kg):68.32±12.31比72.12±11.50,P<0.05〕;D≥10.5 g/L组移植物受体重量比(graft to recipient weight radio,GRWR)、供肝的冷缺血时间、无肝期时间及术中失血量均高于D<10.5 g/L组〔GRWR(%):0.81±0.23比0.74±0.20,供肝冷缺血时间(min):9.86±2.66比8.85±2.45,无肝期时间(min):48.95±19.59比44.11±9.35,术中失血量(L):2.73±1.58比2.08±1.70,P<0.05〕;D≥10.5 g/L组AR的发生率高于D<10.5 g/L组(P<0.05)。多因素回归分析结果显示冷缺血时间、术中失血是肝移植术后D≥10.5g/L的独立危险因素,其他变量均无统计学意义。170例受者累积1和3年生存率分别是88.4%和77.6%,D≥10.5 g/L组1和3年受者存活率分别是86.1%和77.1%;而D<10.5 g/L组1和3年受者存活率分别是90.8%和78.4%,差异无统计学意义(P>0.05)。结论肝移植术后早期球蛋白降低是手术后无法避免的可逆的过程,降低的程度可能与术中冷缺血时间及术中失血量有关,且球蛋白降低程度高组术后AR发生率高,但对受者生存预后无影响。

Objective To investigate the early changes of serum globulin and the risk factors influence to the reduction of serum globulin,and analyze its impact on short-term incidence of acute rejection（AR） and prognosis for patients after liver transplantation（LT）. Methods A total number of 170 patients who underwent cadaveric donor LT from Jan-Dec 2011 in our hospital were followed and the data has been statistical processing,median reduction level（D） of postoperative day（POD） 1 compared with pre-operation was used as the cut off,85 patients in D≥10.5 g/L group,85 patients in D〈10.5 g/L group. The general information,surgical data,postoperative rejection and living conditions in recipients were retrospectively collected,and the risk factors that influence the recipients post operation globulin level and 1-year,3-years cumulative survival rate were analyzed. Results As compared with pre-operative globulin,two groups decreased significantly on POD 1,then gradually increased. The POD 1 globulin level of D≥10.5 g/L group was higher than that of D〈10.5 g/L group（P〈0.05）,there was no statistical significance at other time points（P〈0.05）. Compared with D〈10.5 g/L group,patients in D≥10.5 g/L group had a lower weight 〔weight（kg）：68.32±12.31 vs. 72.12±11.50,P〈0.05〕; and graft to recipient weight radio（GRWR）,cold ischemia time,the time of anhepatic phase,intraoperative blood loss in D ≥ 10.5 g/L group were higher than which in D10.5 g/L group 〔GRWR（%）：0.81±0.23 vs. 0.74±0.20,cold ischemia time（min）：9.86±2.66 vs. 8.85±2.45,the time of anhepatic phase（min）：48.95±19.59 vs. 44.11±9.35,intraoperative blood loss（L）：2.73±1.58 vs. 2.08±1.70,P〈0.05〕; and incidence of acute rejection was higher too（P〈0.05）. Logistic regression analysis showed that cold ischemia time and intraoperative blood loss were independent prognostic factors for D≥10.5 g/L after LT. 1-year,3-year cumulative survival rate of 170 recipients was 88.4% and 77.6%,1-year,3-year cumulative survival rate in D≥10.5 g/L group was 86.1% and 77.1%,and that in D10.5 g/L was 90.8% and 78.4%（P〉0.05）. Conclusion The early reduction of serum globulin after LT was inevitable and reversible process,and the reduction degree of globulin was associated with cold ischemia time and intraoperative blood loss,and the high reduction degree group had higher incidence of acute rejection,however the reduction degree had no impact on survival prognosis for patients after LT.