非生物型人工肝在肝脏移植围手术期的应用

目的总结人工肝脏支持系统（artificial liver support system ALSS）应用于人体原位肝脏移植围手术期的经验体会，原位肝移植加人工肝支持疗法对急慢性肝功能衰竭的应用及人工肝支持系统在急慢性肝功能衰竭肝移植术前准备和术后辅助中的作用。方法回顾分析2001年7月-2004年5月浙江省温州医学院附属第一医院感染内科实施的21例肝脏移植中4例患者在移植前后进行ALSS治疗的临床资料。本组4例患者，均有不同程度的肝昏迷、黄疸、腹水、肝功能损害，出血倾向。在等待供肝的过程中及移植术后分别接受2～11次非生物型人工肝支持疗法，供肝到达后行原位肝移植术。结果人：人工肝支持治疗后患者血清胆红素明显下降，腹水明显减少，部分患者肝性脑病有所好转。4例均顺利行肝移植，3例存活6～20个月，其中2例已存活1年以上，并已逐步恢复正常工作，1例术后10天脑死亡。结论ALSS能纠正机体术前的内环境失衡，为供肝等待和增加手术耐受创造条件，应作为肝脏移植前积极准备的重要部分，术前人工肝支持可作为暴发性肝功能衰竭等待供肝期间的桥梁，并可改善病情减少肝移植的危险因素；ALSS为术后移植物功能发挥欠佳者提供了有力支持和恢复功能的机会。原位肝移植加人工肝支持疗法是急慢性肝功能衰竭的有效方法。     

混合型生物人工肝治疗重型肝炎的临床研究

目的 观察以血浆置换和猪肝细胞型生物人工肝构成的混合型生物人工肝对急性或亚急性重症肝炎肝功能衰竭的治疗效果并了解其安全性。方法 5例重型肝炎患者分别诊断为急性重型(ALF)3例和亚急性重型(sALF)2例,在内科治疗基础上配合混合型生物人工肝(HBL)治疗。于治疗前、治疗中、治疗后分别观察临床症状、体征、肝功能、血氨、PTA及内毒素水平变化。结果 5例患者4例乏力、腹胀明显减轻,3例伴肝性脑病患者意识状态均有好转。与治疗前比较,患者TBIL明显降低(P<0.01),PTA及CHE显著升高(P<0.05),血清内毒素水平降低(P<0.01)。治疗中未发生出血、过敏等不良反应。2例患者痊愈,1例1周后成功实施肝移植,其余2例分别存活8日和21日。结论 混合型生物人工肝可有效改善重型肝炎肝衰竭患者乏力、腹胀等临床症状及肝功能,升高PTA,降低内毒素水平。患者耐受较好,未见严重不良反应。     

肝移植围手术期辅助应用MARS人工肝的护理

【目的】探讨肝移植围手术期MARS人工肝的护理经验。【方法】总结19例慢性肝功能衰竭患者在肝移植术前、术中、术后行MARS人工肝辅助治疗49人次的护理体会。【结果】所有患者在MARS治疗后症状都有改善,肝肾功能指标有不同程度的好转,15例平稳过渡到肝移植。【结论】MARS人工肝是肝移植围术期间安全有效的辅助治疗方法,熟练规范的护理操作和观察是治疗成功的基础。     

人工肝血浆置换术在药物性肝功能衰竭患者中的应用

目的 探讨药物性肝功能衰竭患者行人工肝血浆置换术治疗后的临床效果,并观察相关并发症的护理防治措施.方法 采用回顾性的研究方法,收集2012年7月至2015年7月在本院感染内科住院的100例药物性肝功能衰竭患者的临床资料,所有患者在给予常规方法治疗的基础上(如降酶、退黄、护肝等),进一步给予人工肝血浆置换术治疗.观察患者治疗前、治疗后的凝血功能、肝功能相关指标的动态改变及自觉症状(如纳差、恶心、腹痛等)的改变状况,并进一步归纳患者行人工肝血浆置换术后相关的并发症,探讨并发症出现的因素和相关护理防治方法.结果 大部分患者行人工肝血浆置换术治疗后,纳差、恶心、腹痛等不适症状明显减轻,生命体征较之前明显改善;人工肝治疗后患者的血清丙氨酸氨基转移酶、总胆红素明显降低,与治疗前比较,差异有统计学意义(P<0.05);治疗后,患者的血清白蛋白、凝血功能明显增高,与治疗前比较,差异有统计学意义(P<0.05);治疗后,相关并发症的出现率分别是:对血浆过敏11例(11%)、血压降低5例(5%)、插管处出血2例(2%).结论 药物性肝功能衰竭患者采用人工肝血浆置换术治疗,能显著改善患者的肝功能,大大提高了药物性肝功能衰竭患者的救治成功率,值得临床推广应用.     

肝移植术后的护理

肝移植手术是治疗不可逆性急、慢性肝功能衰竭最有效方法.肝移植标准手术方式是原位肝移植,即将移植肝与受者肝上及肝下下腔静脉、门静脉、脾动脉和胆总管分别作端端吻合;背驮式肝移植是保留受者下腔静脉原位肝移植,与标准式原位肝移植不同,其优点是当供肝上下腔静脉吻合完成后,可一直维持下腔静脉回心血流.本院于2001年12月至2003年7月对10例患者进行了肝移植手术,经过多学科协作,术后患者恢复良好.现将护理报告如下.     

肝移植围手术期中的人工肝支持

人工肝脏支持系统是以血液净化为基础的体外循环系统,包括血液透析、血液滤过、血液灌流、血浆置换等方法.临床应用非生物型人工肝脏尤其是血浆置换技术,能有效地解决高胆红素血症、内毒素血症、毒性物质积蓄与氨基酸代谢障碍及水、电解质、酸碱失衡等问题,改善患者内环境,促进肝细胞再生,纠正肝性脑病、降低重型肝炎的病死率,使患者能渡过危险的肝功能衰竭难关而获得生存.通过人工肝治疗,不仅可明显改善肝衰竭患者的全身情况,为手术降低风险,为寻找供肝争得保贵的时间,而且能有效地改善肝移植术后早期患者的生理紊乱状况.帮助渡过排斥反应期,有利于移植肝功能的恢复.因此,人工肝可成为肝移植的桥梁.文章从人工肝脏支持系统的功能出发,分析其特点,探讨其应用于人体原位肝移植围手术期的方法及其发展方向.     

MARS人工肝治疗肝功能衰竭临床研究

目的评价分子吸附再循环系统(MARS)治疗肝功能衰竭的治疗效果与安全性。方法兰州大学第一医院感染科2002年1月～2004年10月对12例患者在内科综合治疗的基础上,加用MARS人工肝治疗。在MARS人工肝治疗前后测定肝肾功能、凝血酶原活动度、电解质等指标。结果12例患者治疗后临床症状明显改善,总胆红素明显下降(P<0.05),血清肌酐和尿素氮清除显著(P<0.05),而凝血酶原活动度、电解质等指标无显著变化(P>0.05)。12例患者7例存活(存活率58.3%)。结论MARS人工肝治疗肝功能衰竭能有效改善临床症状,显著改善部分生化指标,提高近期存活率,是一种安全可行的治疗方法。     

人工肝血浆置换术治疗药物性亚急性肝功能衰竭患者的护理

目的探讨人工肝血浆置换术治疗药物性亚急性肝功能衰竭患者的临床观察与并发症防范护理措施。方法回顾性分析2007年12月至2010年12月温州医学院附属第一医院收治的50例药物性亚急性肝功能衰竭患者的临床资料,所有患者均在护肝、降酶等综合治疗的基础上进行血浆置换治疗。分析治疗前后患者肝功能、凝血功能的变化和临床症状如乏力、食欲缺乏、腹胀等改善情况以及对人工肝治疗中出现的并发症情况,总结并发症的发生原因及预防护理措施。结果人工肝治疗后,多数患者临床症状明显改善,表现为精神好转,乏力、腹胀及消化道症状明显减轻;治疗后血清总胆红素、丙氨酸氨基转移酶明显下降,白蛋白、凝血指标升高。并发症发生率高低依次为血浆过敏反应(6人次)、低血压(2人次)、插管处出血(1人次)。结论人工肝血浆置换术治疗药物性亚急性肝功能衰竭,可以改善患者肝功能,提高早、中期患者救治成功率;提倡尽早予以人工肝治疗。规范、细致的临床护理是提高人工肝血浆置换术治疗药物性亚急性肝功能衰竭成功率的重要保证,正确预防处理并发症是提高治疗安全性的关键。     

间充质干细胞向肝细胞分化的研究进展

中毒性损伤、病毒感染、自身免疫或遗传性疾病均可导致肝功能异常,继而引起慢性肝病或导致急性肝功能衰竭。肝脏移植目前仍是治疗急性肝功能衰竭和终末期肝病最有效的方法。但由于肝源的短缺及高昂的医疗费用,肝移植并非适合每个患者。另一方面,施行肝移植后患者可能出现排异、原发疾病的复发及免疫抑制剂的副作用等。因此,有必要发展一种可取代传统肝移植的治疗方法。肝细胞移植和生物人工肝被认为是有前途的方法。在过去20年里,干细胞因其自身具有自我更新及多向分化能力而受到广泛关注。     

肝移植术后神经系统并发症的防治分析

目的 探讨原位肝移植术后早期神经系统并发症的相关问题及处理.方法 回顾2003 年1 月至2010 年10 解放军107 医院完成的168 例肝脏移植患者中并发神经系统并发症的30 例患者的临床资料,并结合相关文献进行分析.结果 168 例原位肝移植患者中30 例并发神经系统并发症(17.8%),28 例并发移植后脑病,2 例并发移植后癫痫.肝功能衰竭患者肝移植术后神经系统的并发症高于肝癌患者.急性生理学及慢性健康状况评分(APACHE 评分)20 分以上患者肝移植术后神经系统的并发症高于APACHE 评分20 分以下的.结论 中枢神经系统病变的存在、免疫抑制药物的毒性、代谢紊乱、感染及其他一些药物等均可能导致肝脏移植术后神经系统并发症的发生; 早期神经系统并发症的预防及治疗是取得原位肝移植术后预后成功的关键之一.     

人工肝支持联合肝移植治疗重型肝炎的临床探讨

目的观察人工肝支持系统联合肝移植治疗重型肝炎的应用价值.方法采用血浆置换和持续性血液透析滤过两种人工肝支持疗法,对本例肝移植的晚期重型肝炎患者进行人工肝过渡支持,3天后成功等到供体肝移值.结果本例经人工肝支持治疗,肝衰竭得到较好控制,最后肝移植取得成功.结论人工肝支持系统对等待肝移植的重型肝炎患者有一定的过渡支持作用,肝移植是彻底纠正肝衰竭的最可靠手段.     

Outcome of orthotopic liver transplantation in the aetiological and clinical variants of acute liver failure

Thirty-three patients with acute liver failure underwent orthotopic liver transplantation, including 16 with fulminant hepatic failure, 15 with late-onset hepatic failure and two with severe acute liver failure (coagulopathy without encephalopathy). Twenty-three (70 per cent) survived to leave hospital and 21 of these are currently alive and well. Outcome correlated with the serum bilirubin level before transplantation (p less than 0.05) but no correlation was found with the variant of acute liver failure, grade of encephalopathy, cerebral oedema, serum creatinine, white cell count, prothrombin time or platelet count at the time of transplantation. Severe coagulation factor deficiencies did not constitute a clinical problem. One patient developed a neurological deficit secondary to cerebral oedema, but otherwise the morbidity reflected that observed in the general population after transplantation. Careful monitoring of intracranial pressure and surveillance (with early aggressive therapy) for bacterial and fungal infections is very important in achieving a successful outcome after transplantation.     

同一机构5年原位肝移植726例术后并发肝动脉血栓形成14例资料回顾

背景：虽然肝移植技术已经成熟,但肝动脉血栓形成仍是造成肝移植后移植物丢失的重要原因之一,肝动脉血栓形成如果不能及早发现处理,只有再次肝移植才能挽救患者生命。目的：总结原位肝移植后并发肝动脉血栓形成的治疗体会。方法：中山大学附属第一医院器官移植中心从2004-01/2009-12共实施726例成人尸肝移植,共14例患者经造影证实在肝移植后出现肝动脉血栓形成,回顾性分析以上14例患者的临床资料。结果与结论：肝动脉血栓形成的发生率为1.9%（14/726）,发生的平均时间为移植后10d（1～41d）。14例肝动脉血栓形成患者中,6例表现为急性的肝功能恶化,4例表现为胆漏,1例表现为肝脓肿,3例无明显临床症状。3例行急诊肝动脉再血管化,2例行肝动脉溶栓治疗,3例行肝动脉再血管化联合肝动脉局溶栓治疗,6例行再次肝移植。本组肝动脉血栓形成相关的死亡率为42.9%（6/14）,其中2例行肝动脉再血管化后因胆道坏死、肝功能衰竭死亡;1例溶栓后再次血栓形成并发多器官功能衰竭死亡;1例肝动脉再血管化联合肝动脉溶栓后因肾功能衰竭、严重感染死亡;2例再次移植后早期因严重感染死亡。8例患者康复出院,并常规随访18～66个月,其中2例患者分别于肝移植后18,29个月因肝癌复发死亡,以上患者随访过程中移植肝功能正常,肝动脉畅通。提示肝动脉血栓形成是肝移植后的严重并发症,在造成不可逆的胆道和肝实质损伤前,尽早恢复肝动脉血流可以避免再次肝移植。     

Clinical management of acute hepatic failure

Acute hepatic failure is a rare clinical syndrome associated with high mortality. Hepatic failure leads to a well-recognised pattern of clinical signs and symptoms, sometimes with rapid deterioration and progression to multi-organ failure. Early recognition of this syndrome is essential for appropriate treatment; once identified, patients benefit from early interventional support and treatment in the intensive care unit. Aggressive management may allow stabilisation of patients before their transfer to specialist liver units. At present, orthotopic liver transplantation is the only treatment modality that provides significant improvement in outcome. This review examines the aetiology and clinical presentation of acute hepatic failure, providing guidelines regarding patient management. We present a critical appraisal of specific clinical areas, including the management of cardiovascular, cerebral, renal, coagulopathic and infective complications. Liver transplantation is discussed as well as emerging therapies including non-biological and hybrid liver support systems that may provide a "bridge to transplantation".     

Early detection of hepatic artery thrombosis after liver transplantation by Doppler ultrasonography: prognostic implications.

We assessed the usefulness of routine Doppler ultrasonography for early detection of hepatic artery thrombosis after orthotopic liver transplantation and repercussions in patient prognosis. Seventeen confirmed cases of early hepatic artery thrombosis initially diagnosed by Doppler ultrasonography (10 of them before clinical indication) were reviewed. All patients underwent Doppler ultrasonographic studies in the first 3 days after orthotopic liver transplantation. Twelve cases of hepatic artery thrombosis (70.6%) were detected by this early Doppler ultrasonography. All 10 unsuspected cases of hepatic artery thrombosis and 5 of the 7 cases diagnosed after clinical indication were treated by revascularization. Grafts were salvaged in 80% of asymptomatic patients and in 42.8% of symptomatic patients. Furthermore, biliary complications were less serious in the first group. In conclusion, Doppler ultrasonography performed routinely in the first 3 days after orthotopic liver transplantation may permit early detection of hepatic artery thrombosis, even before clinical indications. This allows hepatic artery repermeabilization before liver function damage, improving graft rescue and patient prognosis.     

Conventional care of fulminant hepatic failure: medical and surgical aspects.

Fulminant hepatic failure (FHF) is a clinical syndrome with a poor outcome. Survival rates are between 10% and 40% depending on the etiology of hepatic necrosis. Multiple supportive modalities have been tried to improve patient outcome. However, orthotopic liver transplantation has been shown to be the most effective therapy at improving survival. Management of these patients requires invasive monitoring, mechanical ventilation, and infection prophylaxis, all of which are conducted most efficiently in specialized units. The goal is to allow the native liver to regenerate and to prevent the development of complications while maintaining the patient in a condition suitable for orthotopic liver transplantation. Therapeutic plasma exchange improves survival in patients with sufficient residual capacity for regeneration. It is effective in restoring hemostasis, improving neurological function, and prolonging biochemical stability of patients awaiting liver transplantation. Hepatoprotective and hepatotrophic substances are still in the experimental stage. Auxiliary liver grafting and artificial liver support devices have proved to be an adjunct or a bridge to transplantation; however, they are not yet widely available.     

探讨人工肝支持治疗对判断重型肝炎患者预后的临床意义

目的 观察161例经人工肝治疗的重症肝炎患者的转归,探讨人工肝治疗对判断患者预后的临床意义。方法 161例重症肝炎肝功能衰竭患者各行血浆置换(plasma exchange,PE)、胆红素特异性吸附(bilirubin specific adsorption,BSA)、活性炭灌流(hemoperfusion,HP)、分子吸附循环系统(molecular adsorbent recy—cling system,MARS)、组合型生物人工肝(hybrid bioartificial liver,HBL)、人工肝治疗,平均治疗2.7次。于治疗前、治疗中、治疗后分4个不同时段取血分别测肝功能、血氨、凝血酶原活动度及血清内毒素水乎,并观察临床症状及体征变化。结果 20例治疗前伴肝性脑病患者昏迷程度减轻。与治疗前比较,患者血清总胆红素及内毒素水平明显降低(P<0.01),凝血酶原活动度及胆碱脂酶显著升高(P<0.O1和P<0.05)。92例患者痊愈,33例成功的实施肝移植,其余36例分别死于严重感染者、消化道大出血和肝肾综合征,存活率为77.64％。结论 人工肝可能作为治疗重型肝炎肝衰竭的有效方法之一,并作为判断患者能否自然恢复或必须进行肝移植的主要指标。     

Liver transplantation in exertional heat stroke: a medical dilemma

Background Exertional heat stroke (EHS) is a life-threatening condition caused by an extreme elevation in core body temperature. Hepatic involvement is one of the hallmarks of heat stroke, affecting nearly all heat stroke patients. It is usually manifested by increased serum levels of liver enzymes, but acute liver failure has also been reported. Liver transplantation has been proposed as a potential treatment in cases of severe liver failure, but there are no unanimous criteria pointing to the right stage in which to conduct the transplantation.Case presentation We report a case of an 18-year old patient who suffered heat-induced liver failure. The patient was referred for orthotopic liver transplantation (OLT) but spontaneously recovered completely with conservative treatment.Conclusions This case demonstrates the complexity of the decision for liver transplantation in EHS. The various prognostic criteria of acute hepatic failure and their relevance to EHS are critically reviewed, with an aim to assess their application for such a condition.     

Acute liver failure

Acute liver failure is a rare and life-threatening clinical syndrome following severe hepatic injury. Depending on the rapidity of its development, two distinct complications contribute to a high mortality: in hyperacute liver failure, rapid development of massive hepatic necrosis and apoptosis gives rise to severe hyperammonemia, hepatic encephalopathy and life-threatening cerebral edema. The high risk of cerebral herniation requires early listing for emergency liver transplantation. Patients with hyperacute liver failure surviving the initial episode of cerebral edema have a substantial potential for hepatic recovery. If progressive hepatic failure develops more slowly, astrocytic osmoregulation prevents cerebral herniation in most instances. Unfortunately, these patients have a small potential of hepatic regeneration and transplantation should be performed before renal failure, sepsis or multiorgan failure emerge. Experimental treatment methods including detoxification by artificial or bioartificial liver support or by stimulating hepatic regeneration are currently evaluated. Recognition of ammonia toxicity has stimulated the search for early ammonia-lowering strategies and strongly renewed the interest in dialytic therapies. Anti-apoptotic interventions are among the most promising pharmacological options for the near future.