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中华普通外科学文献(电子版) ›› 2021, Vol. 15 ›› Issue (03) : 161 -167. doi: 10.3877/cma.j.issn.1674-0793.2021.03.001

所属专题: 文献

论著

肝移植术后原发性移植物无功能的临床特点和危险因素分析:单中心报道
何淑娇1, 陈世锐1, 罗涛1, 唐云华1, 郭志勇1,(), 何晓顺1   
  1. 1. 510080 广州,中山大学附属第一医院器官移植科
  • 收稿日期:2020-12-08 出版日期:2021-06-01
  • 通信作者: 郭志勇
  • 基金资助:
    国家自然科学基金资助项目(81970564); 中大高校基本科研业务费青年教师重点培育项目(19ykzd13)

Clinical features and outcomes of primary non-function after liver transplantation: A single-center report

Shujiao He1, Shirui Chen1, Tao Luo1, Yunhua Tang1, Zhiyong Guo1,(), Xiaoshun He1   

  1. 1. Organ Transplant Center, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
  • Received:2020-12-08 Published:2021-06-01
  • Corresponding author: Zhiyong Guo
引用本文:

何淑娇, 陈世锐, 罗涛, 唐云华, 郭志勇, 何晓顺. 肝移植术后原发性移植物无功能的临床特点和危险因素分析:单中心报道[J/OL]. 中华普通外科学文献(电子版), 2021, 15(03): 161-167.

Shujiao He, Shirui Chen, Tao Luo, Yunhua Tang, Zhiyong Guo, Xiaoshun He. Clinical features and outcomes of primary non-function after liver transplantation: A single-center report[J/OL]. Chinese Archives of General Surgery(Electronic Edition), 2021, 15(03): 161-167.

目的

探讨本中心公民器官捐献时代肝移植术后原发性移植物无功能(PNF)的临床特点及危险因素。

方法

回顾性分析2015年1月至2019年12月间中山大学附属第一医院647例实施成年肝移植患者的临床资料、实验室参数和随访结果。

结果

研究期间术后29例(4.48%)发生PNF,表现为肝脏合成功能和代谢功能障碍,丙氨酸氨基转移酶(ALT)、天冬氨酸氨基转移酶(AST)和总胆红素(TBIL)迅速升高和伴有严重的凝血功能障碍。单因素和多因素分析发现,术前肾脏替代治疗、手术总时长和供体风险指数(DRI)是PNF的独立危险因素,其中DRI预测PNF的最佳临界值为2.24(AUC=0.756,P=0.002)。

结论

PNF是肝移植术后少见的严重并发症,再次肝移植是唯一有效的治疗方法。术前肾脏替代治疗、手术总时长和DRI是肝移植术后发生PNF的独立危险因素,并且DRI>2.24可能是预测PNF的有效指标,可以作为供肝弃用及使用常温机械灌注技术的重要参考。

Objective

To investigate the clinical characteristics and risk factors of primary non-function (PNF) after liver transplantation in the era of volunteer deceased organ donation in our center.

Methods

Clinical data, laboratory parameters and follow-up results of 647 adult liver transplantation patients in the First Affiliated Hospital of Sun Yat-sen University from January 2015 to December 2019 were retrospectively analyzed.

Results

During the study period, PNF occurred in 29 patients (4.48%) post-transplantation. The functional characteristics of PNF patients were liver synthesis and metabolic dysfunction, with alanine aminotransferase (ALT), aspartate aminotransferase (AST) and total bilirubin (TBIL) rapidly rising, accompanied by severe coagulation dysfunction. Univariate and multivariate analysis showed that preoperative kidney replacement therapy, total duration of operation and donor risk index (DRI) were independent risk factors for PNF, in which DRI>2.24 was the best critical point for predicting PNF (AUC=0.756, P=0.002).

Conclusions

PNF is a rare and serious complication after liver transplantation, and re-transplantation is the only effective treatment. It is found that preoperative kidney replacement therapy, total duration of operation and DRI are independent risk factors for PNF, and DRI>2.24 appears to be a potential predictor of PNF, which may help to discard a donor liver or attempt to use normothermic machine perfusion for organ preservation.

表1 供体临床资料表
表2 受体临床资料表
项目 总数(647例) non-PNF组(618例) PNF组(29例) P
受体术前特征        
  年龄(岁) 50(41~58) 50(41~58) 51(41~57) 0.917
  性别[例(%)]       0.837
    526(81.3) 502(81.2) 24(82.8)  
    121(18.7) 116(18.8) 5(17.2)  
  体质指数(kg/m2) 23.3(20.8~25.1) 23.3(20.8~24.9) 23.8(22.5~26.4) 0.038
  主要诊断[例(%)]       0.014
    重型肝炎 131(20.2) 119(19.3) 12(41.4)  
    肝硬化 143(22.1) 139(22.5) 4(13.8)  
    肝细胞癌 346(53.5) 333(53.8) 13(44.8)  
    胆管细胞癌 11(1.7) 11(1.8) 0(0)  
    其他 16(2.5) 16(2.6) 0(0)  
  合并症[例(%)]        
    高血压 56(8.7) 54(8.7) 2(6.9) 0.763
    糖尿病 50(7.7) 48(7.8) 2(6.9) 0.903
  术前感染[例(%)] 68(10.5) 60(9.7) 8(27.6) 0.007
  MELD评分 13.0(8.7~21.9) 13.0(8.6~21.4) 21.3(10.6~40.5) 0.002
  Child-Pugh评分 7(6~9) 7(6~9) 9(6~11) 0.013
  术前肾脏替代治疗[例(%)] 36(5.6) 28(4.5) 8(27.6) <0.001
术中数据        
  无肝期(min) 56(43~66) 56(43~66) 60(48~75) 0.090
  手术时长(h) 7.8(6.7~8.9) 7.8(6.6~8.9) 8.8(7.5~9.9) 0.012
  出血量(U) 8(5~15) 8(5~15) 25(10~45) <0.001
  输红细胞量(U) 5(3~9) 5(3~9) 16(5~22) <0.001
  输新鲜冰冻血浆量(U) 8(5~11) 8(5~11) 11(8~18) <0.001
  静脉输液总量(L) 9.0(7.1~11.1) 8.9(7~11) 1.2(9.2~18.0) <0.001
受体术后特征        
  术后住院时间(d) 24(17~35) 24(18~35) 3(1~7) <0.001
  呼吸支持时长(h) 17.8(11.0~48.0) 17.0(11.0~45.8) 65.0(15.0~128.0) 0.004
  住院期间死亡[例(%)] 42(6.5) 20(3.2) 22(75.9) <0.001
  ALT 7 d峰值(U/L) 639(319~1 191) 612(317~1 154) 1 280(677~2 580) 0.001
  AST 7 d峰值(U/L) 1 400(667~3 232) 1 362(654~2 997) 6 961(3 119~10 759) <0.001
  TBIL 7 d峰值(μmol/L) 153(81~269) 152(81~266) 192(91~414) 0.294
  GGT 7 d峰值(U/L) 251(154~395) 256(162~403) 75(34~122) <0.001
  INR 7 d峰值 1.50(1.35~1.81) 1.50(1.34~1.78) 2.64(2.16~3.19) <0.001
  CREA 7 d峰值(umol/L) 93(75~136) 92(74~127) 249(134~324) <0.001
  2周患者存活[例(%)] 616(95.2) 614(99.4) 2(6.9) <0.001
  2周移植物存活[例(%)] 614(94.9) 613(99.2) 1(3.4) <0.001
  1个月患者存活[例(%)] 599(92.6) 597(96.6) 2(6.9) <0.001
  1个月移植物存活[例(%)] 597(92.3) 596(96.4) 1(3.4) <0.001
图1 PNF组和non-PNF组的术后7 d内肝功能指标的峰值比较 A~D指标分别是血清丙氨酸氨基转移酶(ALT)、血清天冬氨酸氨基转移酶(AST)、总胆红素(TBIL)和国际化标准比值(INR)
表3 肝移植术后PNF的单因素和多因素分析
图2 DRI分数预测PNF的ROC曲线分析
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