血浆灌流联合血浆置换治疗慢加急性肝衰竭的效果观察

Clinical effect of plasma perfusion combined with plasma exchange in treatment of patients with acute-on-chronic liver failure

目的评价血浆灌流(PP)联合血浆置换(PE)治疗慢加急性肝衰竭(ACLF)的临床价值。方法收集2014年1月-2015年12月兰州市第二人民医院感染科收治的72例ACLF患者,所有患者均在内科药物治疗基础上加用人工肝支持系统治疗(根据病情不同,3~4 d进行1次人工肝治疗,平均每例患者进行1~3次),据治疗方法不同分为联合组(n=40,PP联合PE治疗,共107例次)和对照组(n=32,单纯PE治疗,共85例次)。记录患者治疗前、术后及术后72 h的TBil、ALT和PTA。并在治疗4周后进行疗效评价。计量资料2组间比较采用t检验;计数资料2组间比较用χ~2检验。结果所有患者的总有效率为63.89%(46/72);术后72 h联合组和对照组患者的ALT水平比较,差异有统计学意义[(319.54±86.23)U/L vs(354.75±100.76)U/L,t=2.60,P<0.05)];与治疗前比较,2组患者的TBil、ALT水平在术后(联合组:t值分别为6.69、15.84,P<0.05,对照组:t值分别为5.34、14.38,P<0.05)及术后72 h(联合组:t值分别为3.24、8.83,P<0.05,对照组:t值分别为2.40、4.61,P<0.05)均有降低;2组患者的PTA水平在术后与治疗前比较变化明显,差异有统计学意义(t值分别为4.83、5.01,P值均<0.05)。联合组和对照组皮肤瘙痒、皮疹的发生率差异无统计学意义;口周或肢体麻木的发生率差异有统计学意义(10.28%vs 31.76%,χ~2=9.11,P<0.05)。结论 PE联合PP与单纯PE治疗均可有效改善ACLF患者的临床疗效,2组治疗有效率近似;但联合组可节省40%~50%血浆,且降低了PE治疗不良反应的发生率,安全性更高,同时更符合目前血源紧缺的社会现实,是临床治疗手段的更佳选择。

Objective To investigate the clinical effect of plasma perfusion（PP） combined with plasma exchange（PE） in the treatment of acute-on-chronic liver failure（ACLF）.Methods A total of 72 patients with ACLF who were admitted to The Second People＇s Hospital of Lanzhou from January 2014 to December 2015 were enrolled.In addition to internal medication,all the patients were treated with the artificial liver support system（once every 3-4 days based on the patients＇ conditions,1-3 times on average for each patient）.According to the difference in therapies,the patients were divided into combination group with 40 patients（PP combined with PE and a total of 107 case times） and control group with 32 patients（PE alone and a total of 85 case times）.Total bilirubin（TBil）,alanine aminotransferase（ALT）,and prothrombin time were recorded before treatment,after surgery,and at 72 hours after surgery.Clinical outcome was evaluated after 4 weeks of treatment.The t-test was used for comparison of continuous data between groups,and the chi-square test was used for comparison of categorical data between groups.Results The overall response rate of all patients was 63.89%（46/72）.At 72 hours after surgery,there was a significant difference in the level of ALT between the combination group and the control group（319.54 ± 86.23 U/L vs354.75 ± 100.76 U/L,t=2.60,P〈0.05）.Both groups had significant reductions in TBil and ALT after surgery（combination group： t =6.69 and 15.84,P〈0.05; control group： t=5.34 and 14.38,P〈0.05） and at 72 hours after surgery（combination group： t=3.24 and8.83,P〈0.05; control group： t=2.40 and 4.61,P〈0.05）.Both groups had significant changes in prothrombin time activity after surgery（t=4.83 and 5.01,both P〈0.05）.There were no significant differences in the incidence rates of pruritus and rash between the two groups,while there was a significant difference in the incidence rate of perioral or limb numbness between the two groups（10.28% vs31.76%,χ^2=9.11,P〈0.05）.Conclusion Both PE combined with PP and PE alone can effectively improve the clinical outcome of ACLF patients with similar response rates; however,PE combined with PP can save the amount of plasma by 40%-50% and reduce the incidence of the adverse effects of PE and has higher safety.Meanwhile,it is in accordance with the social reality of a shortage of blood resources.Therefore,it is a better choice in clinical treatment.