MELD评分系统评估慢性肝损伤患者肝脏储备功能的临床研究

目的：探索MELD 评分评估慢性肝损伤患者肝脏储备功能的价值。
方法：回顾性分析38例慢性肝损伤性肝脏移植患者术前测定的MELD 评分,同时采用计算机辅助数字图像分析法检测患者肝组织标本的纤维化程度,分析MELD 评分系统与肝组织纤维化图像定量分析的相互关系。
结果：慢性肝损伤患者的MELD 评分与肝纤维化面积百分比呈直线正相关;Child A,B,C 3组间MELD评分差异也有统计学意义。
结论：MELD 评分能准确评估慢性肝损伤患者的肝脏储备功能。     

终末期肝病模型评分对梗阻性黄疸手术风险的评估价值

目的研究终末期肝病模型评分(model for end-stage-liver disease,MELD)对梗阻性黄疸手术风险的评估价值。方法选取梗阻性黄疸患者98例,随机分为观察组和对照组,各49例,按照MELD评分结果将两组患者分为3个小组。观察组患者于Ⅰ期行经皮穿肝胆管引流术(PTCD),Ⅱ期再行开腹手术,解除胆道梗阻。对照组患者未经PTCD,直接行开腹手术,解除胆道梗阻。结果观察组MELD评分10分组的手术时间、术中出血量、住院时间及术后并发症与对照组相同MELD评分小组无明显差别(P0.05)。观察组10分≤MELD20分组及MELD≥20分组的手术时间、术中出血量、住院时间及术后并发症均优于对照组相同MELD评分小组(P0.05)。结论 MELD评分在评估围手术期梗阻性黄疸患者的肝脏储备功能、手术风险方面具有指导价值。     

MELD评分在肝硬化患者预后评估中作用的临床研究

目的探讨MELD(Model For End-StageLiver Disease)评分在评估肝硬化患者预后及肝脏储备功能中方面的作用。方法分析我院从2005年8月至2009年7月收治外科病房的429例肝硬化患者的临床资料,对照MELD评分,Child-Pugh分级,肝脏体积及吲哚氰绿(Indocyanine greenICG)试验数值,分析肝硬化患者预后情况,各个评分体系之间的关系。结果 MELD评分与Child-Pugh分级生存组与死亡组比较均有明显差异(P0.01),MELD评分与Child-Pugh分级两体系的ROC曲线面积有差异(P0.01)。MELD评分,Child-Pugh分级与肝脏体积有相关性(P0.01),肝脏体积与MELD评分的相关系数大于Child-Pugh分级。Child-Pugh分级与吲哚氰绿试验指标(K值,R15)有相关性(P0.05);MELD评分与吲哚氰绿试验指标(K值,R15)有显著相关性(P0.01)。结论相对于传统的Child-Pugh分级,MELD评分能更好的预测患者预后,特异度,敏感度更高,精确性更好,MELD评分与肝脏体积,肝脏储备功能间存在明显相关性,且相关性明显好于Child-Pugh分级,作为评价患者预后,MELD评分体系更可靠,更能间接反映出肝脏的储备功能。     

30例肝移植病例MELD分析

目的探讨终末期肝病模型（MELD）评分评估终末期肝病患者行肝移植术后,受者短期预后、肝移植的手术时机以及MELD与肝脏病理的关系。方法对30例肝移植病例进行回顾性分析,比较术后随访30天后存活组（12例）与死亡组（18例）的术前MELD评分,以MELD分值25和30为界线将病例分组,比较存活率以及肝脏病理,分析大块、亚大块肝细胞坏死与非大块、亚大块肝细胞坏死病例的MELD分值。结果所有患者术前MELD评分平均值为28．92±13．45,术后随访3个月总生存率为40％,其中存活组与死亡组术前MELD评分分别为21．56±11．83和33．82±12．43（P〈0．05）;以MELD评分25为界将患者分为两组,术后3个月存活率为63．6％和26．3％（P〈0．05）;以MELD评分30为界将患者分为两组,术后3个月存活率为53．3％和26．7％（P〉0．05）：大块、亚大块肝细胞坏死组与非大块、亚大块肝细胞坏死组患者术前MELD值相比有显著差异,分别为22．38±12．69和33．28±12．41（P〈0．05）。结论MELD评分可评估肝移植受术者的短期预后,肝移植受者MELD评分值在25分时比30分时行肝移植术更有意义,MELD评分与肝细胞坏死面积有关。     

肝硬化肝癌患者行ALPPS的利弊分析(附3例报道)

目的通过对实施ALPPS手术的3例伴肝硬化巨大肝癌(平均肿瘤直径12.6 cm)患者资料的分析,初步探讨其利弊。方法回顾性分析笔者所在医院3例实施ALPPS手术患者的资料,通过对术前评估、术中及术后的治疗要点分析以探讨其利弊。结果 1例因肝功能衰竭死亡,另外2例存活至今。死亡病例第2次术后MELD评分最高升至18.8分,另外2例第2次术后MELD评分均下降。肝脏体积平均增加225 m L,2次手术前相比,肝脏体积明显增加(P=0.002)。结论 ALPPS使得一部分伴肝硬化的巨大肝癌患者获得手术切除的机会,但应综合考虑患者术前状态、评估手术风险、预后判断以及经济状况来决定患者能否从ALPPS获益更多。     

Child-Pugh分级、终末期肝病模型与肝硬化患者术后并发症的关系

为了对肝硬化患者肝功能储备、手术风险及预后作出一个正确的评估，一直采用Child—Pugh分级。2001年Malincho等提出了新的评价系统，即终末期肝病模型。（Model for end—stage liver disease，MELD）。本文应用MELD评分系统和Child—Pugh分级回顾性分析96例行脾切除加贲门周围血管离断术患者的术后并发症，以了解它们之间的关系。     

终末期肝病模型在肝癌破裂出血急诊术前评估中的应用

目的探讨终末期肝病模型（MELD）评估肝储备功能在原发性肝癌破裂出血中确定急诊手术适应证的应用价值。方法2002年1月至2005年4月间在传统的手术适应证标准的基础上联合MELD评估后,急诊肝切除治疗肝癌破裂出血18例。结果全部病例MELD分值〈18,均值为（13.3±4．2）分。18例患者均顺利完成手术,无围手术期死亡。15例获得随访,生存时间为4～51个月。1、3年生存率分别为66．7％（10／15）、33．3％（5／15）。结论在经过临床选择的病例中,急诊肝切除治疗原发性肝癌破裂出血是安全可行的,疗效显著。MELD评分简单,能够客观地反映肝储备功能,对原发性肝癌破裂出血确定合理的治疗方案有重要的参考价值。     

吲哚氰绿清除试验在半肝切除术中应用的价值

目的 探讨半肝切除术中测定吲哚氰绿15 min潴留率(ICGR15)在原发性肝癌手术中评估残余肝脏储备功能的价值.方法 44例原发性肝癌患者术中阻断待切除侧肝动脉和门静脉后,应用肝功能储备分析仪检测ICGR15.同时记录患者术前Child-Pugh评分、Child-Pugh分级及MELD评分,并评价患者术后肝功能恢复情况.结果 手术后共有17例患者出现肝功能不全,其中肝功能代偿轻度不全14例,重度不全3例.术中ICGR15<10%者术后肝功能不全发生率为17.9%(5/28),明显低于10%～15%者的75.0%(12/16),差异有统计学意义(P<0.05).Child-Pugh评分在肝功能恢复良好者、肝功能代偿轻度不全者和肝功能代偿重度不全者之间的差异无统计学意义(P>0.05); 而肝功能恢复良好者的ICGR15及MELD评分则明显低于肝功能代偿轻度和重度不全者(P<0.05).术前Child-Pugh A级者其术中ICGR15明显低于Child-Pugh B级者(P<0.05).结论 术中残余肝脏的ICGR15检测比传统的Child-Pugh评分更能准确地评估残余肝脏储备功能,可用于指导制定手术方案.     

MELD评分系统在肝移植中的应用和意义

目的 讨论终末期肝病模型（MELD）的产生与发展，评价对肝移植的影响。方法回顾性分析MELD在肝移植应用中的有关文献。结果MELD广泛应用于预测和评定终末期肝病的严重程度及患者等待肝移植期间死亡危险度，以决定器官分配的优先顺序。结论MELD为新的评分系统，可减少患者等待肝移植的时间，客观地、精确地预测终末期肝病患者的短期生存率和死亡危险度，是较为理想的器官分配评分系统。     

MELD评分与肝移植围手术期并发症及死亡率的相关性

目的探讨MELD评分与肝移植围手术期并发症及死亡率之间的关系。方法回顾性分析160例肝移植患者的临床资料。以肝移植前最后一次检测血清胆红素、肌酐、凝血酶原时间的国际标准化比值(INR)为依据,计算患者的MELD评分。根据MELD评分的不同将患者分成3组。A组:MELD评分<15分81例(50.6%);B组:MELD评分为15～24分45例(28.1%);C组:MELD评分≥25分34例(21.3%)。分别统计各组患者术中情况、围手术期并发症及死亡情况。结果MELD评分高的患者平均手术时间较长,术中平均出血量较多,与MELD评分低的患者比较,差异有统计学意义(P<0.01)。MELD评分高的患者术后肺部严重感染或呼吸衰竭、肾功能衰竭、心血管并发症、移植相关性脑病、腹腔内出血等并发症的发生率以及围手术期死亡率均较高,与MELD评分低的患者相比较,差异有统计学意义(P<0.05)。各组的无肝期时间、围手术期胆道并发症、血管并发症及排斥反应的发生率相比较,差异无统计学意义。结论MELD评分与肝移植围手术期肝外重要脏器并发症的发生率及患者死亡率之间存在着密切的相关性。MELD评分≥25分的患者是肝移植的高危受者,应加强围手术期重要脏器功能的调理及支持。     

Anesthesia in the patient with impaired liver function

We review information on impaired liver function, focusing on concepts relevant to anesthesia and postoperative recovery. The effects of impaired function are analyzed by systems of the body, with attention to the complications the patient with liver cirrhosis may develop according to type of surgery. Approaches to correcting coagulation disorders in the cirrhotic patient are particularly controversial because an increase in volume may be a factor in bleeding owing to increased portal venous pressure and imbalances in the factors that favor or inhibit coagulation. Perioperative morbidity and mortality correlate closely to Child-Pugh class and the score derived from the model for end-stage liver disease (MELD). Patients in Child class A are at moderate risk and surgery is therefore not contraindicated. Patients in Child class C or with a MELD score over 20, on the other hand, are at high risk and should not undergo elective surgical procedures. Abdominal surgery is generally considered to put patients with impaired liver function at high risk because it causes changes in hepatic blood flow and increases intraoperative bleeding because of high portal venous pressures.     

血清前白蛋白检测评价肝功能损害的临床应用

目的 探讨血清前白蛋白浓度测定在临床肝功能损害评价中的价值.方法 分析80例接受脾切除+贲门周围血管离断术的肝硬化患者术前血清前白蛋白(PA)水平、终末期肝病模型(MELD)与术后出现肝功能衰竭的关系.结果 术后出现肝功能衰竭的患者术前的PA值为(79.8±28.5)mg/L,较术后未出现肝功能衰竭情况患者的术前PA值(149.6±31.5)mg/L明显降低(P＜0.01).单独使用MELD评分≥9分和PA值＜100mg/L来判断肝硬化门脉高压患者术后是否出现肝功能衰竭的敏感性分别为71.4%和69.6%,使用MELD评分联合PA值来判断术后是否出现肝功能衰竭的敏感性为82.4%,明显高于单独使用MELD和PA值(P＜0.01).单独使用MELD评分≥9分、PA值＜100 mg/L和MELD评分联合PA值三种方法对术后肝功能衰竭情况评价的特异性都较强,分别为93%、91.5%和90.5%,但三种方法之间的差异无统计学意义(P＞0.05).结论 前白蛋白可反映乙肝后肝硬化门脉高压患者的肝功能损害程度.术前MELD评分联合PA值评估术后是否出现肝功能衰竭情况有良好的敏感性及特异性,可应用于临床.

Abstract：

Objective To investigate the clinical use of serum prealbumin (PA) in evaluating liver function damage. Methods Preoperative PA and the model for end-stage liver disease (MELD) score were retrospectively analyzed in 80 patients with liver cirrhosis and portal hypertension undergoing splenectomy and devascularization around the cardia. The correlation of preoperative PA level and MELD score with postoperative hepatic failure was also analyzed. Results The mean serum value of PA in the patients with hepatic failure was (79. 8 ± 28.5 ) mg/L, and that in thouse without hepatic failure was ( 149. 6 ±31.5 ) mg/L ( P ＜ 0. 01 ). The sensitivity of using MELD score ≥9 to evaluate postoperative hepatic failure was 71.4%, that of PA ＜ 100 mg/L was 69. 6%, and that of MELD score ≥9 combined with PA ＜ 100mg/L was 82. 4% respectively (P ＜0. 01 ). The specificity of the three methods was 93%, 91.5% and 90. 5% respectively, with the difference being not significant (P ＞ 0. 05). Conclusion The serum level of PA could reflect the liver function damage sensitively and exactly. Preoperative MELD score combined with serum PA has good sensitivity and specificity in predicting postoperative hepatic failure and could be used clinically.     

Recovery from liver failure after hepatectomy for hepatocellular carcinoma in cirrhosis: meaning of the model for end-stage liver disease

BACKGROUND: Hepatectomy for hepatocellular carcinoma in cirrhosis is followed by an impairment of liver function that can lead to patient death. The model for end-stage liver disease (MELD) is considered an index of hepatic functional reserve, and its assessment on postoperative course may properly identify individuals at risk of liver failure. STUDY DESIGN: Two hundred hepatectomies for hepatocellular carcinoma in cirrhosis were reviewed. Irreversible postoperative liver failure was defined as an impairment of liver function after hepatectomy that led to patient death or required transplantation. The MELD scores at postoperative days (POD) 1, 3, 5, and 7 were calculated and kinetics of changes investigated with t-test; logistic regression was applied to identify predictive variables of postoperative liver failure. RESULTS: Kinetics of postoperative MELD score showed an impairment of liver function between PODs 1 and 3; 185 patients in whom postoperative liver failure did not develop showed a considerable decrease in MELD score between PODs 3 and 5 (11.9+/-2.8 and 10.6+/-2.4, respectively, p<0.001). On the contrary, 15 patients, who experienced the event, showed an increase in MELD score between PODs 3 and 5 (18.2+/-3.9 and 18.3+/-3.6, respectively; p=0.845). Multivariate analysis showed preoperative MELD score (p<0.001), major hepatectomy (p=0.028), and MELD score increase between PODs 3 and 5 (p=0.011) as independent predictors of irreversible postoperative liver failure. Scores are reported as mean+/-SD. CONCLUSIONS: Recovery from liver impairment after hepatectomy for hepatocellular carcinoma in cirrhosis starts from POD 3; MELD scores increasing between PODs 3 and 5 may identify patients at risk of liver failure and represents the trigger for beginning intensive treatment or evaluating salvage transplantation.     

Chronic Kidney Disease-Epidemiology Formula and Model for End-Stage Liver Disease Score in the Assessment of Renal Function in Candidates for Liver Transplantation

Assessment of renal function in patients with end-stage liver disease (ESLD) awaiting liver transplantation (OLT) is critical. Various conditions may cause renal damage in ESLD. Renal and liver functions are intertwined due to splanchnic hemodynamic relationships; renal failure rarely occurs in patients without advanced decompensated cirrhosis. The recent literature suggests that evaluation of renal function should include an assessment of liver function. The aim of this study was to evaluate different methods to estimate glomerular filtration rate (GFR) in patient among ESLD candidates for OLT over 1 year. We also correlated renal and hepatic functions. Fifty-two cirrhotic patients Model for End-Stage Liver Disease [MELD] > 10) were enrolled in the study. All patients were evaluated at baseline and every 4 months (T1-T4) thereafter for 1 year. The GFR was calculated by creatinine clearance, and estimated by Cockroft and Gault, Modified Diet Renal Disease (MDRD) 4 and 6 variable and Chronic Kidney Disease-Epidemiology (CKD-EPI) formulae. Hepatic functions were evaluated by MELD score, albumin, bilirubin, and International Normalized Ratio (INR). We observed not statistically significant increase mean value of MELD score, bilirubin, serum creatinine, and blood urea nitrogen and a reduced serum sodium. There were no significant differences among various methods to evaluate GFR at each time over 1 year. We did not observe any association between renal and hepatic function, except at T4 for MELD and GFR estimated with MDRD 4 (P = .009) and 6 (P = .008) parameters or CKD-EPI (P = .036), and MELD and sodium (P = .001). Our results showed that evaluation of renal function in cirrhosis should include an evaluation of hepatic function. In our case, MDRD and CKD-EPI seemed to be the more accurate formulae to evaluate renal function in relation to hepatic function.     

Model for end-stage liver disease score versus simplified acute physiology score criteria in acute renal failure after liver transplantation

Hepatic function and renal failure are closely related among patients with end-stage liver disease (ESLD) due to splanchnic hemodynamic mechanisms that characterize advanced decompensated cirrhosis. Acute renal failure (ARF) is a frequent complication that occurs immediately post-orthotopic liver transplantation (OLT). The Model for End-stage Liver Disease (MELD) score describes the survival of patients with ESLD awaiting OLT related to the severity of liver disease. The Simplified Acute Physiology Score (SAPS II) is a mortality prediction model that scores the severity of illness among intensive care unit patients. In a previous study we observed an association between ARF post-OLT and a higher MELD score, but it was not clear whether this association depends on the grade of ESLD or on the critical condition of liver transplant patients. The aim of this study was to evaluate the association of ARF with MELD score and/or SAPS II criteria among liver transplant patients. We analyzed 46 patients with ESLD who underwent deceased donor OLT. All patients were evaluated at baseline and in the first 7 days post-OLT. According to the RIFLE classification, the incidence of the worst grade of ARF post-OLT was 19.2%. These patients showed significantly higher MELD scores, while there was no association with systemic parameters related to the critical patient's condition or with the mortality score as evaluated by SAPS II criteria. We confirmed the association between renal failure and hepatic function among liver transplant patients. A more severe degree of hepatic dysfunction before OLT was associated with a greater incidence of ARF that can adversely affect patient survival.     

终末期肝病模型评分较高的良性终末期肝病患者肝移植疗效评价

目的 探讨终末期肝病模型(MELD)评分较高的良性终末期肝病患者的肝移植疗效.方法 回顾分析80例良性终末期肝病肝移植患者的资料,根据MELD评分的不同将患者分成两组,MELD评分≥30分的23例为高MELD评分组,MELD评分＜30分的57例为低MELD评分组.分别比较两组患者手术时间、术中无肝期、术中血液制品输入量、术后重症监护病房(ICU)治疗时间和受者1年存活率,同时比较死亡患者和存活患者的临床资料,寻找导致术后死亡的危险因素.结果 高MELD评分组的手术时间、术中血液制品输入量、ICU治疗时间以及术后3个月内的死亡率明显高于低MELD评分组,差异有统计学意义(P＜0.05),而术中无肝期和患者1年存活率,两组间的差异无统计学意义(P＞0.05).死亡者和存活者相比较,MELD评分的差异无统计学意义(P＞0.05),而术前机械通气、血清钠水平、持续性肝性脑病(重型)等方面的差异有统计学意义(P＜0.05).结论 对于良性终末期肝病患者,单纯依靠MELD评分不足以准确判断患者肝移植术后的生存状态,高MELD评分者也可获得较好的肝移植结果,术前严重的低钠血症、重度肝性脑病以及机械通气是除MELD评分以外影响患者术后生存状况的危险因素.     

Effects of artificial liver support system on patients with acute or chronic liver failure

AIMS: Acute on chronic liver failure (AoCLF) is associated with a high mortality rate. Artificial liver support system (ALSS) is useful to bridge patients with liver failure to liver transplantation or to regenerate their own livers. The aims of this prospective study were to investigate the effects of ALSS on clinical manifestations, liver function, and 30-day survival to probe the factors related to mortality in patients with AoCLF. METHODS: In this study, 338 enrolled patients with AoCLF who received ALSS treatment for 1 to 8 sessions, were compared with 312 patients treated with conventional medications. RESULTS: Clinical manifestations and liver functions were significantly improved, namely, decreased levels of serum transaminases, total bilirubin, and bile acid, as well as increased levels of serum albumin following ALSS treatment. The 30-day survival rates of the patients who received ALSS versus controls were 47.9% versus 34.6%, respectively (P = .01). The MELD score and the stage of hepatic encephalopathy were highly associated with mortality (P < .001), but the sessions of ALSS showed a positive relation to the 30-day survival (P < .05). CONCLUSIONS: ALSS appears to be efficacious and safe for the treatment of patients with AoCLF. Both model for end-stage liver disease (MELD) score and hepatic encephalopathy are useful to predict the mortality of patients.     

Hepatic flow optimization in full right split liver transplantation

Split liver transplantation for two adults offers a valuable opportunity to expand the donor pool for adult recipients.However,its application is mainly hampered by the physiological limits of these partial grafts.Small for size syndrome is a major concern during transplantation with partial graft and different techniques have been developed in living donor liver transplantation to prevent the graft dysfunction.Herein,we report the first application of synergic approaches to optimise the hepatic hemodynamic in a split liver graft for two adults. A Caucasian woman underwent liver transplantation for alcoholic cirrhosis(MELD 21)with a full right liver graft (S5-S8)without middle hepatic vein.Minor and accessory inferior hepatic veins were preserved by splitting the vena cava;V5 and V8 were anastomosed with a donor venous iliac patch.After implantation,a 16G catheter was advanced in the main portal trunk.Inflow modulation was achieved by splenic artery ligation.Intraportal infusion of PGE1 was started intraoperatively and discontinued after 5 d.Graft function was immediate withnormalization of liver test after 7 d.Nineteen months after transplantation,liver function is normal and graft volume is 110%of the recipient standard liver volume. Optimisation of the venous outflow,inflow modulation and intraportal infusion of PGE1 may represent a valuable synergic strategy to prevent the graft dysfunction and it may increase the safety of split liver graft for two adults.