心脏死亡器官捐献肝移植的临床疗效

Clinical outcomes in liver transplantation from donation after cardiac death

    摘要
  • 摘要: 目的:探讨心脏死亡器官捐献(DCD)肝移植的临床疗效。
    方法:回顾性分析2008年12月至2013年7月天津市第一中心医院收治的52例行心脏死亡器官捐献(DCD)肝移植终末期肝病患者的临床资料，其中未成年患者(年龄<18岁)21例，成人患者(年龄≥18岁)31例。分析患者术中、术后及预后情况。出院后患者通过天津市第一中心医院东方器官移植随访中心定期随访，随访时间截至2014年7月31日。正态分布的计量资料以±s表示，组间比较采用重复测量的方差分析。累积生存率采用KaplanMeier法计算。
    结果:21例未成年受者中16例行原位肝移植，5例采用成人DCD供肝行劈离式肝移植。供肝质量、移植物与受者体质量比(GRWR)、热缺血时间、冷缺血时间、无肝期时间、静脉输液总量、手术时间、术中出血量分别为(338±34)g、1.9%±0.7%、(16±6)min、(86±36)min、(43±10)min、(816±662)mL、(7.1±1.5)h、(329±214)mL。患者术后未发生腹腔积液、急性细胞排斥反应、门静脉血栓形成及胆道并发症。术后住院时间为(41±23)d。未成年受者Hb和Alb由术前水平逐渐增加，至术后14 d达到正常水平分别为(101±19)g/L～(128±23)g/L和(34±7)g/L～(44±7)g/L，手术前后比较，差异均有统计学意义(F=3.943，7.340，P<0.05)。血清TBiL、AST、ALT由术前水平逐渐降低，至术后14 d接近正常水平，分别为(307±69)μmol/L～(34±17)μmol/L、(88±34)U/L～(36±17)U/L、(154±51)U/L～(46±18)U/L，手术前后比较，差异均有统计学意义(F=142.200，17.060，31.750，P<0.05)。31例成人受者均采用成人DCD供肝，手术方式均为原位肝移植。供肝质量、GRWR、热缺血时间、冷缺血时间、无肝期时间、静脉输液总量、手术时间、术中出血量分别为(1 104±43)g、1.7%±0.4%、(16±4)min、(89±43)min、(47±9)min、(2 515±1 803)mL、(7.9±1.8)h、(1 208±548)mL。术后14例患者发生并发症，其中腹腔积液8例、急性细胞排斥反应3例、门静脉血栓形成2例、胆道并发症1例。术后住院时间为(44±22)d。成人受者术后Alb水平逐渐增加，至术后14 d达到正常水平(31±5)g/L～(40±5)g/L，手术前后比较，差异有统计学意义(F=14.930，P<0.05)。血清TBiL、AST、ALT由术前水平逐渐降低，至术后14 d接近正常水平，分别为(182±55)μmol/L～(62±22)μmol/L、(286±93)U/L～(79±47)U/L、(349±111)U/L～(76±28)U/L，手术前后比较，差异有统计学意义(F=34.350，71.070，82.680，P<0.05)。52例患者均获得随访，中位随访时间为544 d(196～1 953 d)。患者1年生存率为90.38%。随访期间未成年受者因肺部感染和大出血各死亡1例；成人受者因肺部感染、原发性移植物功能障碍、大出血各死亡1例。
    结论:DCD肝移植是治疗终末期肝病可行的选择，患者可获得良好的短期临床疗效。

     

    Abstract: Objective:To investigate the clinical outcomes in liver transplantation from donation after cardiac death (DCD).
    Methods:The clinical data of 52 patients with end stage liver disease who received liver transplantation from DCD donors ( the age of 21 pediatric recipients ＜18 years, and the age of 31 adult recipients ≥18 years) at the Tianjin First Central Hospital from December 2008 to July 2013 were retrospectively analyzed. The intraoperative, postoperative and prognosis data were analyzed. All patients were regularly followed up in 〖HJ*4〗the Transplantation Followup Center after discharge till July 31, 2014.  The measurement data with normal distribution were presented as ±s. The comparison between groups was evaluated with the repeated measures ANOVA.  The cumulative survival rate was done by the KaplanMeier method.
    Results:Among the 21 pediatric recipients, 16 received classic orthotopical liver transplantation and 5 received reducedsize liver transplantation from adult donors. The weight of 21 DCD livers, graft to recipient weight ratio (GRWR), warm ischemia time, cold ischemia time, anhepatic phase, volume of intravenous infusion, operation time and volume of intraoperative blood loss were (338±34)g, 1.9%±0.7%, (16±6)minutes, (86±36)minutes, (43±10)minutes, (816±662)mL, (7.1±1.5)hours and (329±214)mL, respectively. No peritoneal effusion,  acute cellular rejection (ACR), portal vein thrombosis (PVT) and biliary complications occurred in the pediatric recipients. The duration of hospital stay was (41±23)days. The level of hemoglobin (Hb) and albumin (Alb) to reach the normal level from preoperation to postoperative day 14 were (101±19)g/L to (128±23)g/L and (34±7)g/L to (44±7)g/L, respectively, with significant differences (F=3.943, 7.340, P<0.05). The level of total bilirubin (TBil), aspartate transaminase (AST) and alanine transaminase (ALT) gradual reducing to the normal level from preoperation to postoperative day 14 were (307±69)μmol/L to (34±17) μmol/L, (88±34)U/L to (36±17)U/L and (154±51)U/L to (46±18)U/L, respectively, with significant differences (F=142.200, 17.060, 31.750, P<0.05). Thirtyone adult recipients received classic orthotopical liver transplantation form adult donors. The weight of 21 DCD livers, GRWR, warm ischemia time, cold ischemia time, anhepatic phase, volume of intravenous infusion, operation time and volume of blood loss were(1 104±43)g, 1.7%±0.4%, (16±4)minutes, (89±43)minutes, (47±9)minutes, (2 515±1 803)mL, (7.9±1.8)hours and (1 208±548)mL, respectively. The complications occurred in 14 adult recipients, including peritoneal effusion in 8 recipients, ACR in 3 recipients, PVT in 2 recipients and biliary complications in 1 recipient. The duration of hospital stay was (44±22)days. The level of Alb to reach the normal level from preoperation to postoperative day 14 were(31±5)g/L to (40±5)g/L, with a significant difference (F=14.930, P<0.05). The level of TBil, AST and ALT gradual reducing to the nearly normal level from preoperation to postoperative day 14 were (182±55)μmol/L to (62±22)μmol/L, (286±93)U/L to (79±47)U/L and (349±111)U/L to (76±28)U/L, respectively, with significant differences (F=34.350, 71.070, 82.680, P<0.05). All the 52 recipients were followed up for a median time of 544 days (range, 196-1 953 days), with 1year survival rate of 90.38%. During the followup, 1 pediatric recipient died of pulmonary infection and 1 of massive hemorrhage, and 1 adult recipient died of pulmonary infection, 1 of primary graft dysfunction and 1 of massive hemorrhage.
    Conclusion:Liver transplantation from DCD is a feasible treatment for endstage liver diseases, with a good shortterm clinical outcomes.

     

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