体外膜肺氧合对循环不稳定脑死亡器官捐献的肝肾功能修复效果

Extra corporeal membrane oxygenation （ECMO） in deceased donors after brain death with severe hemodynamic instability allows to optimize the viability of livers and kidneys procured for transplantation

目的探索体外膜肺氧合（ECMO）应用于循环功能不稳定的脑死亡器官捐献供者肝肾功能的保护效果。方法2011年6月至2017年4月共99例符合中国一类（即国际标准化脑死亡器官捐献）的供者实施器官捐献程序。供者在器官获取前出现中重度的血流动力学不稳定，部分器官功能出现不同程度受损。经股动静脉插管，根据体重、血流动力学及血液气体分析结果，调整ECMO流量，转流时间为6～18 h，并在ECMO转流支持下获取供肝和供肾。结果99例脑死亡供者行ECMO转流期间，血流动力学逐步稳定，血管活性药物应用明显减少，甚至停用，受损的器官功能明显恢复，产出经病理活检证实可用于移植的器官240个，其中肾脏183个、肝脏57个。供肾分配至同一中心并实施177例肾移植，手术均顺利完成，其中术后发生原发性移植肾功能恢复延迟37例（占20.9%），急性排斥反应23例（占12.99%）。共183例肾移植受者痊愈出院，移植肾均良好。结论ECMO对于血流动力学不稳定的脑死亡供者的肝肾功能具有保护和修复作用。

ObjectiveTo observe the clinical effect of the maintenance for the liver and kidney function by extra corporeal membrane oxygenation （ECMO） in brain death donor with severe hemodynamic instability.MethodsNinety-nine brain death donors maintained by ECMO were followed up. The criteria for using the ECMO to protect the organ function were as follow： cardiopulmonary resuscitation history （cardiac compression 〉20 min）; mean arterial pressure （MAP）, for Adult 〈60-70 mmHg, for child 〈50-60 mmHg, and for infant 〈40-50 mmHg; cardiac index 〈2 L/（m2·min） （3 h）; Large doses of vasoactive drugs, for dopamine 20 μg/（kg·min）, for （norepinephrine） epinephrine 1.0 μg/（kg·min） （3 h）, and for oliguria 〈0.5 mL/（kg·h）; blood biochemical indexes, moderate, severe impairment on acute hepatic and renal function; others, ST-T significant changes in electrocardiogram, and difficult to correct the metabolic acidosis （3 h）. The organs were evaluated during their retrieval and as well their evolution after transplantation was evaluated.ResultsECMO allowed for the maintenance of hemodynamic stability before organ procurement. A total of 99 cases receiving ECMO maintenance were collected, equal to100 % of the total donation cases （100%）. 198 kidneys, and 99 livers were procured from these donors meanwhile 15 kidneys and 42 livers respectively were discarded as they were shown in a macroscopic evaluation. 177 of the procured kidneys were transplanted. DGF of kidney transplantation was observed in 20.9% of the cases. Acute rejection incidence was 12.99%. Transplanted kidneys and recipient survival rate was 96.1%/99.3% for one year, 94.7%/97.8% for 3 years, and 93.6/97.8% for 4 years, respectively. There was no significant difference in patient or graft survival between the group with ECMO and the group without ECMO.ConclusionECMO in the brain dead donors with severe circulatory dysfunction allows to avoid organ donors loss and obtain good quality kidneys and livers with excellent graft survival after transplantation.