重型肝炎和肝癌肝硬化患者肝移植围手术期肾功能的变化

目的 观察重型肝炎及肝癌肝硬化患者原位肝移植围手术期肾功能变化,评价肝移植术对该类患者肾功能的影响。方法 选择30例术前血肌酐（SCr）、尿素氮（BUN）正常的终末期肝病、行背驮式原位肝移植术患者,手术过程中均未采用体外静-静脉转流。按原发病不同分为重型肝炎组（15例）和肝癌肝硬化组（肝癌组15例）,分别于术前（麻醉后）、无肝前20min、无肝30min、新肝60min、术毕不同时间点取桡动脉血,测定β2-微球蛋白（β2-MG）值,并记录血流动力学变化;分别于术前、新肝60min、术毕留取新鲜尿液,测定尿β2-MG及尿N-乙酰-β-D-葡萄糖苷酶（NAG）值。记录两组患者术前、术后24h、术后1周的SCr、BUN值以及术后肝移植相关性肾功能衰竭（肾衰）的发生情况。结果1术前重型肝炎组有7例血β2-MG、12例尿β2-MG、14例尿NAG值均高于正常参考值;而肝癌组仅有3例血β2-MG、3例尿β2-MG、7例尿NAG值高于正常参考值;两组各时间点血β2-MG异常率比较差异均无显著性（P均〉0.05）;重型肝炎组术前尿β2-MG及NAG异常率明显高于肝癌组（P〈0.01和P〈0.05）。2术中两组血β2-MG值与术前比较变化不大,变化趋势两时间点间比较差异均无显著性;两组新肝期60min及术毕尿β2-MG及NAG均较术前呈增高趋势,但差异无显著性（P均〉0.05）,而重型肝炎组各时间点尿NAG值明显高于肝癌组（P〈0.05或P〈0.01）。3重型肝炎组肝移植相关性肾衰发生率为46.7%,而肝癌组无一例发生（P〈0.01）。结论 重型肝炎患者较肝癌肝硬化患者肝移植术后早期易发生急性肾衰,围手术期应注意肾功能保护。

Changes in renal function in patients with severe hepatitis and liver cancer with cirrhosis during orthotopic liver transplantation

OBJECTIVE: To observe the changes in renal function in patients with severe hepatitis and liver cancer with cirrhosis during orthotopic liver transplantation (OLT). METHODS: Thirty end-stage liver disease patients with normal blood urea nitrogen (BUN) and serum creatinine (SCr) undergoing OLT were studied. They were divided into two groups: severe hepatitis group (group H, n=15) and liver cancer group (group C, n=15), and all the patients received modified piggyback liver transplantation without veno-venous bypass. During the operation, blood samples were drawn for the determination of serum beta (2)-microglobulin (beta (2)-MG), and the determination was performed at 5 following time points: before operation, 20 minutes before anhepatic phase, 30 minutes in anhepatic, 60 minutes after reperfusion, and the end of operation. Urine samples were collected for determination of urine beta (2)-MG and N-acetyl-beta-D-glucosaminidase (NAG) at 3 time points: before operation, 60 minutes after reperfusion, and the end of operation. The values of SCr and BUN before operation, 24 hours after operation and 1 week after operation. The incidence of renal function failure after liver transplantation in the two groups were recorded respectively. RESULTS: (1)In 7 patients. 12 patients and 14 patients whose serum beta (2)-MG, urine beta (2) MG and urine NAG were higher than normal values, respectively, in group H before operation, and in 3 patients, 3 patients and 7 patients whose serum beta (2)-MG, urine beta (2)-MG and urine NAG, respectively, were higher than normal values in group C before operation. The incidence of abnormal of urine beta (2)-MG and NAG in group H were significantly higher than those in group C (P<0.01, P<0.05 respectively),while there were no significant differences for the abnormal rate of serum beta (2)-MG at every time point between the two groups during operation (all P>0.05). (2)Compared with baseline, serum beta (2)-MG almost had no change in both groups. There were no significant differences in the variation and the mean value of serum beta (2)-MG at every time point between the two groups (all P>0.05). Compared with the baseline,urine beta (2)-MG and urine NAG were increased at 60 minutes after reperfusion and also at the end of operation in both groups, but the differences were not significant (P>0.05). Compared with group C, urine NAG increased at every time point during the operation in group H (P<0.05 or P<0.01). (3)Incidence of renal failure related with liver transplantation (RFALT):46.7% developed RFALT in group H at 24 hours after operation, and there was none in group C(P<0.01). CONCLUSION: Compared with patients with liver cancer with cirrhosis,the damages to renal function in patients with severe hepatitis before operation are more serious, which are mainly due to renal tubular injury. These patients are susceptible to RFALT, and protection of renal function is necessary.