ABO血型不合肝移植治疗O型血重型肝病患者的疗效分析

Clinical retrospective analysis and long-term therapeutic effects of ABO-incompatible liver transplantation on type-O patients with acute severe liver disease

目的 探讨ABO血型不合肝移植治疗O型血重型肝病患者的效果及安全性,分析比较不同血型供肝的临床疗效、术后主要并发症及对应治疗措施.方法 回顾性分析2014年1月至2017年1月间65例O型血重型肝病患者接受急诊肝移植的临床资料,其中ABO血型相合（供、受者血型均为O型）肝移植41例;ABO血型不合肝移植24例,包括血型A型供肝供给O型血受者7例,血型B型供肝供给O型血受者9例,血型AB型供肝供给O型血受者8例.结果 ABO血型不合组受者终末期肝病模型评分为32.5＆#177;5.5,高于ABO血型相合组的23.3＆#177;8.9（P=0.001）.两组受者年龄、受者性别、受者乙型肝炎病毒感染情况、手术时间、供肝冷缺血时间等结果的差异无统计学意义.肝移植后ABO血型相合组和ABO血型不合组受者累积存活率分别为87.8%（36/41）和87.5%（21/24）（P=0.924）.57例存活受者均获随访,随访时间为4~37个月,平均为18个月.ABO血型不合组肝动脉纤细和弥漫性胆道改变发生率分别为29.2%和37.5%,显著高于ABO血型相合组的4.9%和0（P=0.005,P〈0.001）.ABO血型相合组与ABO血型不合组急性排斥反应发生率分别为9.8%（4/41）和4.2%（1/24）,术后感染发生率分别为24.3%（10/41）和29.2%（7/24）,差异均无统计学意义（P=0.463,P=0.598）.结论 不同血型供者肝移植治疗O型血重型肝病患者的安全性良好,与血型相同肝移植比较,受者存活率无明显差异,通过有效的免疫抑制治疗、完善的围手术期管理,对O型重型肝病患者行ABO血型不合的肝移植是可行的.ABO血型相合肝移植肝动脉和胆道并发症发生率低于血型不合肝移植;对于供肝血型不合的O型血肝移植受者,术后合理应用利妥昔单抗、血浆置换等降低血型抗体效价水平是预防、治疗肝动脉和胆道并发症的关键.

Objective To evaluate the long-term prognosis and safety of ABO-incompatible （ABO-I） liver transplantation on type-O patients with acute severe liver disease,analyze and compare the effects and main complications between different donor blood types,and investigate corresponding treatment measures.Methods The clinical data of 65 cases of emergency orthotopic liver transplantation （OLT） for type-O patients with acute severe liver disease from January 2014 to January 2017,including 41 cases of ABO-compatible （ABO-C） OLT and 24 cases of ABO-incompatible OLT （7 with type-A donor,9 with type-B donor,and 8 with type-AB donor） were retrospective analyzed.Results The model for end-stage liver disease （MELD） score in the ABO-incompatible group was 32.5＆#177;5.5,significantly higher in the ABO-compatible group （23.3＆#177;8.9） （P=0.001）.The data of the other perioperative factors showed no statistically significant difference between two groups.The cumulative survival rate in the ABO-compatible group was 87.8 % （36/41）,not significantly different from that in the ABO-incompatible group [87.5% （21/24）,P=0.924].The 57 cases who had survived after perioperative period were followed up for 4-37 months （mean 18 months）.Significantly higher incidence of hepatic artery and biliary complications was found in ABO-incompatible group （P=0.005,and P〈0.001,respectively）.The incidence of hepatic artery complication and biliary complication in ABO-incompatible group was 29.2% （7/24） and 37.5% （9/24）,and that in ABO-compatible group was 4.9% （2/41） and 0 （0/41）,respectively.The rate of acute rejection in the ABO-incompatible group and ABO-compatible group was 9.8% （4/41） and 4.2% （1/24） （P=0.463）.The infection rate in the ABO-compatible group and ABO-incompatible group was 24.3% （10/41） and 29.2%（7/24）,respectively （P=0.598）.Conclusion The different donor blood types including ABO-compatible and ABO-incompatible liver transplantation program on type-O patients with acute severe liver disease have a favorable outcome.The long-term cumulative survival rate between two groups shows no significant difference.With the help of effective immunosuppression and intensive perioperative management,ABO-incompatible liver transplantation is an acceptable option to cure type-O patients with acute liver failure in emergency.The incidence of hepatic artery and biliary complications was lower in ABO-compatible group than in ABO-incompatible group.For the type-O patients with ABO-incompatible liver transplantation,the use of rituximab and plasma exchange to decrease the antibody titers of recipients is essential to prevent and cure the hepatic artery and biliary complications.