肝移植治疗Ⅳ级肝昏迷疗效及其影响因素分析

Efficacy and influencing factors of liver transplantation for grade Ⅳ hepatic coma

目的 探讨肝移植治疗Ⅳ级肝昏迷疗效及其影响因素。方法 回顾性分析2011年1月至2022年12月在第九〇〇医院行肝移植治疗的16例肝昏迷患者临床资料。其中男14例,女2例;年龄29~67岁,中位年龄48岁。患者术前均出现肝性脑病,且符合West-Haven分级Ⅳ级标准(肝昏迷);肝昏迷时间1~14 d,中位时间7 d。患者均签署知情同意书,符合医学伦理学规定。所有患者均接受下腔静脉逆灌注法原位肝移植。根据肝移植术后1年存活情况分为存活组和死亡组,采用t检验、秩和检验、Fisher确切概率法比较两组围手术期情况、术后并发症及生存情况等;分析影响肝移植治疗肝昏迷的疗效及其影响因素。结果 本组1年生存率为63%(10/16),死于原发性移植肝无功能3例,严重感染2例,脑死亡1例。存活组DBD供肝9例,死亡组DBD供肝 2例,差异有统计学意义(P=0.018)。存活组平均术中输血量为(1 840±273)ml,明显低于死亡组的(3 550±1 750)ml(t=-2.640,P<0.05);存活组术后Scr中位数为53(47,109)μmol/L,明显低于死亡组的205(84,278)μmol/L(Z=-2.218,P<0.05);术后WBC(10±4)×10^(9)/L,明显低于死亡组的(15±4)×10^(9)/L(t=-2.787,P<0.05);而存活组术后Plt(62±15)×10^(9)/L,明显高于死亡组的(39±25)×10^(9)/L(t=2.270,P<0.05)。结论 肝移植是挽救Ⅳ级肝昏迷患者生命的有效方法。良好的供肝质量、保护肝肾功能、改善凝血功能、控制严重感染、术中合理输血等围手术期管理是提高肝昏迷肝移植患者术后生存率的关键。

Objective To evaluate the clinical efficacy and its influencing factors of liver transplantation for grade Ⅳ hepatic coma.Methods Clinical data of 16 patients with hepatic coma who underwent liver transplantation in the 900~(th) Hospital from January 2011 to December 2022 were retrospectively analyzed.Among them,14 patients were male and 2 female,aged from 29 to 67 years,with a median age of 48 years.All patients had the symptom of hepatic encephalopathy before surgery,which met the diagnostic criteria of grade Ⅳ hepatic encephalopathy (hepatic coma) according to the West-Haven classification system.The duration of hepatic coma was 1-14 d with a median of 7 d.The informed consents of all patients were obtained and the local ethical committee approval was received.All patients received orthotopic liver transplantation with retrograde perfusion of the inferior vena cava.According to the 1-year survival of post-liver transplantation,they were divided into the survival and death groups.Perioperative conditions,postoperative complications and survival between two groups were compared by t test,rank-sum test and Fisher's exact test.Clinical efficacy and its influencing factors of liver transplantation for hepatic coma were analyzed.Results The 1-year survival rate in the survival group was 63%(10/16),3 cases died of primary graft dysfunction,2 cases of severe infection and 1 case of brain death.In the survival group,9 cases underwent donation after brain death (DBD) donors and 2 cases of DBD donors in the death group,and the difference was statistically significant (P=0.018).In the survival group,the average intraoperative blood transfusion was (1 840±273) ml,significantly less than (3 550±1 750) ml in the death group (t=-2.640,P<0.05).In the survival group,the median Scr level after surgery was 53(47,109) μmol/L,significantly lower than 205(84,278) μmol/L in the death group (Z=-2.218,P<0.05).In the survival group,the postoperative WBC was (10±4)×10^(9)/L,significantly lower than (15±4)×10^(9)/L in the death group (t=-2.787,P<0.05).The Plt in the survival group was (62±15)×10^(9)/L,significantly higher than (39±25)×10^(9)/L in the death group (t=2.270,P<0.05).Conclusions Liver transplantation is an effective life-saving treatment for patients with grade Ⅳ hepatic coma.High-quality donor liver,protection of liver and kidney function,improvement of coagulation function,severe infection control and reasonable intraoperative blood transfusion play key roles in enhancing postoperative survival rate of liver transplantation recipients with hepatic coma.