逆灌注法DCD供肝对肝移植术后早期肝功能恢复的影响及危险因素分析

Effect and risk factors of DCD liver donor with retrograde perfusion on recovery of liver function in early stage after liver transplantation

目的探讨逆灌注法DCD供肝对肝移植术后早期肝功能恢复的影响及其危险因素。方法回顾性分析2015年1月至2020年1月在厦门大学附属东方医院行DCD供肝肝移植术的136例患者临床资料。其中男115例,女21例;年龄20~70岁,中位年龄51岁。患者均签署知情同意书,符合医学伦理学规定。根据供肝灌注方式不同分为逆灌注组(86例)和正灌注组(28例),两组数据通过1∶1倾向性评分匹配后,每组23例,比较两组术后肝功能恢复情况;根据逆灌注组患者术后是否发生早期移植肝功能不全(EAD)将患者进一步分为EAD组(5例)和非EAD组(18例)。采用Logistic回归分析供体因素、供肝灌注方式对肝移植术后EAD的影响,ROC曲线分析影响因素预测价值。结果逆灌注组术后3、7 d的ALT中位数分别为329(211,548)、176(98,282)U/L,明显低于正灌注组的451(288,918)、251(147,430)U/L(Z=-1.979,-2.299;P<0.05)。逆灌注组术后3、5、7 d的AST分为252(193,522)、105(79,163)、93(41,135)U/L,亦明显低于正灌注组的328(251,724)、179(129,306)、150(91,200)U/L(Z=-2.212,-3.221,-2.979;P<0.05)。逆灌注组术后5 d的TB为37(20,106)μmol/L,明显低于正灌注组的185(93,193)μmol/L(Z=-3.871,P<0.05)。Logistic回归分析提示患者终末期肝病模型(MELD)评分是预测肝移植术后EAD的独立危险因素。MELD评分预测术后EAD的ROC曲线下面积为0.678,最佳界值为25.5分。结论逆灌注法DCD供肝对肝移植术后早期肝功能恢复更有利,术前MELD评分>25.5分是逆灌注法肝移植术后发生EAD的独立危险因素。

Objective To evaluate the effect and risk factors of donation after circulatory death(DCD)liver donor treated with retrograde perfusion on recovery of liver function in early stage after liver transplantation(LT).Methods Clinical data of 136 patients who underwent LT with DCD donors in Dongfang Hospital of Xiamen University from January 2015 to January 2020 were retrospectively analyzed.Among them,115 patients were male and 21 female,aged from 20 to 70 years,with a median age of51 years.The informed consents of all patients were obtained and the local ethical committee approval was received.All patients were divided into the retrograde perfusion(n=86)and anterograde perfusion groups(n=28)according to different perfusion methods.After 1∶1 propensity score matching(PSM),23 cases were assigned in each group.Postoperative recovery of liver function was compared between two groups.According to postoperative incidence of early allograft dysfunction(EAD),patients in the retrograde perfusion group were further divided into the EAD(n=5)and non-EAD groups(n=18).The effects of donor factors and donor liver perfusion method on EAD after LT were assessed by Logistic regression analysis.The predictive values of influencing factors were evaluated by the ROC curve.Results In the retrograde perfusion group,the median ALT levels at postoperative 3 and 7 d were 329(211,548)and 176(98,282)U/L,significantly lower than 451(288,918)and 251(147,430)U/L in the anterograde perfusion group(Z=-1.979,-2.299;P<0.05).In the retrograde perfusion group,the AST levels at postoperative 3,5 and 7 d were 252(193,522),105(79,163)and 93(41,135)U/L,significantly lower than 328(251,724),179(129,306)and 150(91,200)U/L in the anterograde perfusion group(Z=-2.212,-3.221,-2.979;P<0.05).In the retrograde perfusion group,the TB levels at postoperative 5 d was 37(20,106)μmol/L,significantly lower than 185(93,193)μmol/L in the anterograde perfusion group(Z=-3.871,P<0.05).Logistic regression analysis suggested that Model for End stage Liver Disease(MELD)score was an independent risk factor for predicting EAD after LT.The area under the ROC curve of MELD score for predicting postoperative EAD was 0.678,and the optimal cut-off value was 25.5.Conclusions DCD liver donor treated with retrograde perfusion is more beneficial to the recovery of liver function in early stage after LT.Preoperative MELD score>25.5 is an independent risk factor for EAD after LT.