乌司他丁对胰-肾联合移植患者围术期心肌损伤的影响

Influence of uinastatin on perioperative myocardial injury in patients undergoing simultaneous pancreas-kidney transplantation

目的探讨乌司他丁对胰-肾联合移植围术期患者心肌损伤的影响,分析其可能的机制。方法选择2018年1月至2020年6月拟行胰-肾联合移植术患者80例,男43例,女37例,年龄18~64岁,BMI 20~25 kg/m^(2),ASAⅡ或Ⅲ级。采用随机数字表法将患者分为两组:对照组(C组)和乌司他丁组(U组),每组40例。U组于麻醉诱导后静脉输注乌司他丁300000 IU,之后每4小时重复输注,直至手术结束。C组于相同时点静脉输注等容量生理盐水。于麻醉诱导后5 min(T_(0))、肾动静脉开放前5 min(T_(1))、肾动静脉开放后30 min(T_(2))、胰腺相关动静脉开放后30 min(T_(3))、术毕即刻(T_(4))、术后4 h(T_(5))、24 h(T_(6))采集中心静脉血6 ml,检测血清TNF-α、IL-6、IL-18、心肌肌钙蛋白I(cTnI)和肌酸激酶同工酶(CK-MB)浓度。记录T_(0)-T_(6)时ECG ST段及T波的变化,记录术中使用多巴胺维持循环灌注、高血压或低血压、心肌缺血和室性早搏的发生情况。结果与T_(0)时比较,T_(2)-T_(6)时两组血清TNF-α、IL-18、cTnI、CK-MB浓度明显升高(P<0.05),T_(2)-T_(5)时C组血清IL-6浓度明显升高(P<0.05),T_(3)时U组血清IL-6浓度明显升高(P<0.05)。与C组比较,U组T_(2)-T_(6)时血清TNF-α、cTnI、CK-MB浓度明显降低(P<0.05),T_(2)-T_(4)时血清IL-6浓度明显降低(P<0.05),T_(3)-T_(6)时血清IL-18浓度明显降低(P<0.05)。T_(2)时C组21例(52%)、U组17例(42%)ECG出现ST段压低或T波高尖;T_(3)时C组26例(65%)、U组19例(48%)ECG出现ST段压低或T波高尖。C组13例(32%)、U组9例(22%)术中使用多巴胺维持循环灌注,两组高血压或低血压、心肌缺血和室性早搏发生率差异均无统计学意义。结论乌司他丁可减轻胰-肾联合移植患者围术期心肌损伤,改善心功能,加速患者康复,其机制可能是通过减少胰-肾联合移植患者围术期炎性因子的释放。

Objective To investigate the influence of ulinastatin on perioperative myocardial injury in patients undergoing simultaneous pancreas-kidney transplantation and to analyze its possible mechanism.Methods Eighty patients underwent simultaneous pancreas-kidney transplantation from January 2018 to June 2020,43 males and 37 females,aged 18-64 years,BMI 20-25 kg/m^(2),ASA physical statusⅡorⅢ,were selected into two groups by random number table method:control group(group C)and uselastatin group(group U),40 patients in each group.Group U administered ulinastatin 300000 IU after anesthesia induction and repeated every 4 hours until the end of the procedure,group C had equal timing for intravenous infusion of equal volume saline.6 ml of central venous blood was collected and serum concentrations of tumor necrosis factor-α(TNF-α),interleukin-6(IL-6),and interleukin-18(IL-18),cardiac troponin I(cTnI),creatine kinase isoenzyme(CK-MB)and the changes in ECG ST segments and T waves were monitored and recorded at 5 minutes after induction of anesthesia(T_(0)),5 minutes before renal arteriovenous opening(T_(1)),30 minutes after renal arteriovenous opening(T_(2)),30 minutes after pancreatic related arteriovenous opening(T_(3)),immediately after surgery(T_(4)),4 hours after surgery(T_(5)),24 hours after surgery(T_(6)).The number of intraoperative circulating perfusion,hypertension or hypotension,myocardial ischemia and ventricular premature beats were recorded.Results Compared with T_(0),the concentrations of TNF-α,IL-18,cTnI,and CK-MB were significantly increased at T_(2)-T_(6) in groups C and U(P<0.05),the concentrations of IL-6 was significantly increased in group C at T_(2)-T_(5)(P<0.05),and the concentration of IL-6 was significantly increased in group U at T_(3)(P<0.05).Compared with group C,the concentrations of TNF-α,cTnI,and CK-MB were significantly reduced in group U at T_(2)-T_(6)(P<0.05),the concentration of IL-6 was significantly reduced in group U at T_(2)-T_(4)(P<0.05),and the concentration of IL-18 was significantly reduced in group U at T_(3)-T_(6)(P<0.05).There were 21 patients(52%)in group C and 17 patients(42%)in group U showed ST segment depression or T wave apex at T_(2),and 26 patients(65%)in group C and 19 patients(48%)in group U showed ST segment depression or T wave apex at T_(3).There were 13 patients(32%)in group C and 9 patients(22%)in group U needed intravenous dopamine infusion to maintain circulatory perfusion.There were no significantly differences in the incidence of hypertension or hypotension,myocardial ischemia and premature ventricular beats between the two groups.Conclusion Uinastatin can reduce perioperative myocardial injury,improve cardiac function,and accelerate the recovery process by reducing the long-operative release of inflammatory factors in pancreatic and kidney transplantation.