合并高钠血症供肝在劈离式肝移植中的应用

Application of liver grafts from hypernatremia donors in split liver transplantation

目的探讨不同程度高钠血症供肝在劈离式肝移植(SLT)中应用的安全性和疗效。方法回顾性分析2017年9月至2022年1月在中山大学附属第三医院行SLT的连续122例供受者临床资料。供受者或(和)家属均签署知情同意书,符合医学伦理学规定。供者均为公民逝世后器官捐献,其中男97例,女25例;年龄4.6~56.8岁,中位年龄27.3岁。受者中,男85例,女37例;年龄0.2~82.8岁,中位年龄8.0岁。供者和受者经过严格筛选和匹配,选择循环稳定的供者,尽可能缩短冷缺血时间(CIT)≤8 h,供肝尽可能选取质地柔软、无或轻微脂肪变(<10%),并优化供肝灌注流程。根据供者血钠浓度将受者分为高钠血症组(160 mmol/L≤血清钠浓度<170 mmol/L,22例)和对照组(血清钠浓度<160 mmol/L,100例)。两组受者CIT、术中出血量比较采用秩和检验;术后7 d早期移植物功能障碍发生率、术后30 d死亡比较采用χ2检验;术后90 d生存情况分析采用Kaplan-Meier法和Log-rank检验。结果高钠血症组CIT和术中出血量中位数分别为445(360,514)min、700(300,1500)ml,对照组相应为450(360,510)min、500(200,1200)ml,差异无统计学意义(Z=-0.182,0.448;P>0.05)。两组受者术后7 d早期移植物功能障碍发生率分别为36%(8/22)、40%(40/100),术后30 d死亡率分别为5%(1/22)、6%(6/100),差异无统计学意义(χ2=0.100,0.071;P>0.05);两组受者术后90 d累积生存率分别为90.9%、93.0%,两组术后生存率比较差异无统计学意义(χ2=0.014,P>0.05)。结论供者血清钠浓度<160 mmol/L的供肝可用于劈离;当160 mmol/L≤血清钠浓度<170 mmol/L时,通过更加严格的脂肪肝评估、CIT控制和优化供肝灌注流程,亦可谨慎安全地实施SLT。

Objective To evaluate the safety and therapeutic effect of liver graft from donors of varying degree hypernatremia in split liver transplantation(SLT)patients.Methods Clinical data of122 consecutive donor-recipients undergoing SLT in the Third Affiliated Hospital of Sun Yat-sen University from September 2017 to January 2022 were analyzed retrospectively.The informed consents of all donors,recipients or(and)their families were obtained and the local ethical committee approval was received.All the liver grafts were from donation after citizen death.Among the donors,97 cases were male and 25 female,aged 4.6-56.8 years,with a median of 27.3 years.Among the recipients,85 cases were male and 37 female,aged 0.2-82.8 years,with a median of 8.0 years.After strict screening and matching of donors and recipients,the donors with stable circulation were selected.The cold ischemia time(CIT)was shortened as much as possible(≤8 h).The liver grafts,which were soft and with no or slight fatty change(<10%),were chosen.The perfusion process of liver grafts was optimized.According to the donors'serum sodium level,the recipients were divided into the hypernatremia group(160 mmol/L≤donor serum sodium level<170 mmol/L,n=22)and control group(donor serum sodium level<160 mmol/L,n=100).The CIT and intraoperative blood loss between two groups were compared by rank-sum test.The incidence of early graft dysfunction within postoperative 7 d and 30 d mortality were statistically analyzed by Chi-square test.The 90 d cumulative survival after SLT was statistically compared by Kaplan-Meier method and Log-rank test.Results The median CIT and intraoperative blood loss in the hypernatremia group were 445(360,514)min,700(300,1500)ml,respectively,and were 450(360,510)min,500(200,1200)ml in the control group,no significant difference was observed between two groups(Z=-0.182,0.448;P>0.05).The incidence of early graft dysfunction within postoperative 7 d in the hypernatremia and control groups were 36%(8/22)and 40%(10/100)respectively,and the 30-d mortality were 5%(1/22)and 6%(6/100)respectively,and no significant difference was observed between two groups(χ2=0.100,0.071;P>0.05).The 90 d cumulative survival after SLT in the hypernatremia and control groups were 90.9%and 93.0%respectively,and no significant difference was observed between two groups in the postoperative survival(χ2=0.014,P>0.05).Conclusions Liver grafts from donors with serum sodium level<160 mmol/L can be applied in SLT.For donors with 160 mmol/L≤serum sodium level<170 mmol/L,SLT can be also performed with caution through strict assessment and selection of fatty liver,control of CIT and optimization of perfusion process.