血清乳酸水平与儿童肝移植术后早期预后的关系

Relationship between serum lactate and early prognosis after liver transplantation in children

目的探讨儿童肝移植术后血清乳酸水平与早期预后的关系。方法回顾性分析2018年1月1日至2020年12月31日间天津市第一中心医院儿童器官移植科共675例儿童肝移植受者的临床资料,统计术后早期血清乳酸水平及清除率,绘制ROC曲线确定最佳截断值。按移植术后12 h血清乳酸浓度是否超过1.99 mol/L,将受者分为高乳酸组(185例)和低乳酸组(490例),比较不同乳酸水平与术后早期(术后3个月内)并发症以及受者、移植物生存率的关系。结果受试者工作特征曲线显示,术后12 h血乳酸水平>1.99 mmol/L同术后早期移植物丢失相关(AUC为0.73,95%CI:0.62~0.84,P=0.01)。高乳酸组受者月龄、体重分别为7.17(5.70~10.40)月和7.00(6.00~8.60)kg,均显著低于低乳酸组的7.80(6.21~13.58)月和7.20(6.45~9.00)kg,组间比较,差异均有统计学意义(P=0.017和0.034)。高乳酸组受者术中输血浆量、输红细胞量、关腹前门静脉压力、术后ICU住院时间、呼吸机使用时间、早期移植物功能不全发生率、术后早期肺感染发生率和受者病死率分别为400(200~400)ml、2.00(2.00~4.00)U、(15.71±4.44)mmHg、2.50(2.00~3.00)d、3.81(2.47~8.50)h、22.95%(42/185)、16.76%(31/185)和6.49%(12/185),均显著高于低乳酸组200(100~400)ml、2.00(2.00~3.00)U、(14.69±4.68)mmHg、2.00(2.00~3.00)d、3.53(2.34~6.12)h、14.69%(72/490)、11.02%(54/490)和1.43%(7/490),且组间差异均有统计学意义(P<0.001,P=0.014、0.015、0.037、0.043、0.011、0.045和P<0.001)。高乳酸组受者术后早期急性细胞性排斥发生率为11.89%(22/185),显著低于低乳酸组的22.86%(112/490),组间比较,差异有统计学意义(P=0.01)。高乳酸组受者和移植物术后1个月、3个月累积生存率分别为94.6%、94.1%和92.4%、91.4%,低乳酸组受者和移植物术后1个月、3个月累积生存率分别为99.2%、98.6%和99.0%、98.4%,组间比较,差异均有统计学意义(P<0.001和P<0.0001)。广义相加模型绘制拟合曲线显示,随术后12 h乳酸水平升高,早期移植物丢失及早期受者死亡风险显著增加(P<0.05)。结论血清乳酸水平是儿童肝移植术后早期预后的有效预测因素。

Objective To explore the relationship between serum lactate level and early prognosis after liver transplantation(LT)in children.Methods Between January 1,2018 and December 31,2020,675 pediatric LT recipients were recruited.Clinical data were retrospectively reviewed,early postoperative serum lactate level and clearance rate recorded and receiver operating characteristic(ROC)curve plotted for determining optimal cut-off values.The inter-group differences in early postoperative complications and patient/graft survival rates were compared.Results According to ROC,blood lactate levels>1.99 mmol/L at 12 h postoperatively were associated with early postoperative graft loss(AUC 0.73,95%CI:0.62-0.84,P=0.01).Age and weight of recipients in high-level group were 7.17(5.70-10.40)month and 7.00(6.00-8.60)kg and both were significantly lower than those in low-level group[7.80(6.21-13.58)month and 7.20(6.45-9.00)kg].The inter-group differences were statistically significant(P=0.017,P=0.034).Blood plasma transfusion volume,red blood cell transfusion volume,portal vein pressure pre-closure,postoperative intensive care unit(ICU)stay,ventilator use time,early allograft dysfunction rate,early postoperative pulmonary infection rate and recipient mortality rate in high-level group were 400(200-400)ml,2.00(2.00-4.00)U,(15.71±4.44)mmHg,2.50(2.00-3.00)day,3.81(2.47-8.50)hour,22.95%(42/185),16.76%(31/185)and 6.49%(12/185)respectively.The above values were significantly higher than those in low-level group 200(100-400)ml,2.00(2.00-3.00)U,(14.69±4.68)mmHg,2.00(2.00-3.00)day,3.53(2.34-6.12)hour,14.69%(72/490),11.02%(54/490)and 1.43%(7/490)respectively.The inter-group differences were statistically significant(P<0.001,P=0.014,P=0.015,P=0.037,P=0.043,P=0.011,P=0.045&P<0.001).The incidence of early postoperative acute cellular rejection was significantly lower in high-level group than that in low-level group[11.89%(22/185)vs 22.86%(112/490)].The inter-group difference was statistically significant(P=0.01).The 1/3-month cumulative survival rates of patient/graft were 94.6%,94.1%and 92.4%,91.4%in high-level group versus 99.2%,98.6%and 99.0%,98.4%in low-level group.There were significant inter-group differences(P=0,P<0.0001).With a rising level of lactate at 12 h postoperatively,risk of early graft loss and early recipient mortality spiked markedly(P<0.05).Conclusions Serum lactate level post-operation is a valid predictor of early prognosis after LT in children.