肝移植后肝功能的异常★

背景：肝移植后导致肝功能异常原因复杂，早期弄清引起肝功能异常的原因对治疗至关重要。目的：较全面的了解肝移植后可以导致肝功能异常的原因，以便应用于临床诊治。方法：应用计算机检索CNKI和FMJS数据库，采用医学主题词检索，检索词为“肝移植；肝功能异常；转氨酶异常；胆红素升高；原因”或“liver transplantation；abnormal liver function；transaminase abnormalities；bilirubin increased, and causes”，时间范围为1991年1月至2012年7月，共检索到98篇文章，选择文章主要内容与肝移植后肝功能异常直接相关的、发表在权威杂志上的文章共35篇进行综述。结果与结论：肝移植后导致肝功能异常的原因众多，临床表现复杂。最常见的原因依次是急性排斥反应、胆道并发症及病毒感染。肝移植后早期，尤其是1个月内出现肝功能异常，需警惕小体积综合征和原发性移植物无功的发生。各种原因引起的肝功能异常，转氨酶及胆红素升高的程度不尽相同。急性排斥反应、自身免疫性肝炎、病毒感染、门静脉及肝静脉狭窄、缺血-再灌注损伤等转氨酶升高较胆红素升高显著；慢性排斥反应、胆道并发症、肝动脉狭窄、原发性胆汁性肝硬化、原发性硬化性胆管炎等早期以梗阻酶碱性磷酸酶、谷氨酰转移酶、总胆红素、直接胆红素升高为主；肿瘤导致的肝功能异常视肿瘤大小、压迫部位不同，可表现出以转氨酶升高为主或以胆红素升高为主。此外，各种原因多有其特殊病史，仔细询问病史有助于早期诊断。临床工作中，应重视尽量详尽的采集病史，根据转氨酶和胆红素升高的具体情况，首先考虑引起肝功能异常的常见原因，经临床证实排除后再考虑其他相对不常见原因，并结合实验室检查、影像学检查及肝脏穿刺病理活检，尽早明确病因及治疗。     

Acute liver failure: liver support therapies

PURPOSE OF REVIEW: We summarize the therapeutic approach to patients with acute liver failure with the main focus on bioartificial and artificial liver support. We also describe specific and general therapeutic approaches based upon recent advances in the understanding of the pathophysiology of acute liver failure. RECENT FINDINGS: Bioartificial liver support systems use hepatocytes in an extracorporeal device connected to the patient's circulation. Artificial liver support is intended to remove protein-bound toxins and water-soluble toxins without providing synthetic function. Both systems improve clinical and biochemical parameters and can be applied safely to patients. Although bioartificial liver-assist devices have not been shown to improve the survival of patients with acute liver failure, further development is underway. Artificial liver support systems have been shown to alter several pathophysiological mechanisms involved in the development of acute liver failure but survival data are still limited. SUMMARY: Mortality in patients with acute liver failure is still unacceptably high. The most effective treatment, liver transplantation, is a limited resource and so other therapeutic options to bridge patients to recovery or stabilization have to be considered. Better understanding of the pathophysiology of acute liver failure and device development is necessary to achieve the elusive goal of effective extracorporeal liver assist.     

Lipid peroxidation of the liver in liver disease

Material of puncture biopsy of the human liver left after morphological study was used to explore enzymatic and non-enzymatic lipid peroxidation, NADH-ferricyanide reductase activity, the content of triglycerides, cholesterol and protein. It was shown that the degree of lipid peroxidation varies considerably in different liver diseases. The highest degree of lipid peroxidation was discovered in patients with fibrosis accompanied by the symptoms of fatty dystrophy. It was established that the rate of peroxidation does not directly correlate with the level of liver lipid infiltration. It is concluded that NADH-ferricyanide reductase activity mirrors adequately the nature of a liver disease and can be used as a highly sensitive and very specific enzymatic test.     

晚期肝癌合并肝包膜下出血或肝破裂出血的护理

目的总结晚期肝癌并肝包膜下出血或肝破裂出血的护理要点。方法2001年1月~2004年12月对本院收治的56例晚期肝癌并肝包膜下出血或肝破裂出血病人进行抢救治疗,并配合护理。结果治疗总有效率为80.4%,死亡率为12.5%。结论晚期肝癌并肝包膜下出血或肝破裂出血,病情变化快,死亡率高,护理的重点在于止痛、止血、并发症的急救、病情观察,心理及支持性的护理,并开展健康教育,尽量消除各种诱发因素,有效地控制出血和防止再出血,从而提高病人的生活质量。     

Management of chronic liver failure until liver transplantation

Chronic liver failure is an important cause of morbidity and mortality and is the long-term consequence of many chronic liver diseases. In addition to determining the specific cause of the chronic liver disease, which may be amenable to targeted therapy, it is important to treat the sequelae of chronic liver failure effectively to improve quality of life, to prolong survival, and to provide a bridge to liver transplantation. Once a patient who has chronic liver failure develops hepatic decompensation, liver transplantation is the definitive treatment for those who qualify. Management of chronic liver failure is the focus of this article.     

Antipyrine kinetics in liver disease and liver transplantation

Antipyrine kinetics were studied in seven normal subjects, 10 patients with liver disease, and 13 clinically stable patients who received a liver transplant. Five patients were studied both before and after liver transplantation. Antipyrine concentrations in saliva after oral dosing were measured by HPLC. The antipyrine t1/2 was significantly longer (P less than 0.05) in patients with liver disease than in patients undergoing liver transplantation and normal subjects. Antipyrine clearance was not significantly different between patients undergoing liver transplantation and normal subjects, but it was significantly reduced (P less than 0.05) in patients with liver disease. In five patients who were studied before and after liver transplantation, there was a significant (P less than 0.05) increase in the antipyrine clearance and a marked reduction in its t1/2 after liver transplantation. These results indicate that liver transplantation improves the drug metabolizing ability of patients with liver disease and that the oxidative metabolizing capacity of the liver in clinically stable patients after liver transplantation is similar to that of normal subjects.     

Shock liver

The clinical syndrome of "shock liver," also known as ischemic hepatitis, is characterized by sudden elevation (to more than 20 times the upper limit of normal) of SGOT and SGPT in response to cellular anoxia, followed by resolution to near normal levels within seven to ten days. In our experience with ten cases, systemic hypotension was documented in only four, but processes characterized by decreased cellular perfusion were identified in all and included cardiac failure or arrhythmia, sepsis, cerebrovascular accidents, renal failure, and chronic obstructive pulmonary disease. We were also able to document the transient rise in serum bilirubin and alkaline phosphatase levels and prolonged prothrombin time that followed the transaminase elevations by 24 to 48 hours in most cases, followed by rapid resolution. In neither of the two cases in which tissue was available by biopsy after resolution of the biochemical abnormalities did we find the classic histologic picture of necrosis in zone 3 ("centrilobular necrosis"). The clinical picture of shock liver is so characteristic and resolves so rapidly that there should be no confusion with other causes of marked elevations of transaminase levels.     

The liver. Part 5: acute liver failure

Clinical complexity presents health professionals with a significant challenge if a patient with ALF is to survive. While efforts to develop pharmacological therapies and biomechanical techniques serve as a bridge to spontaneous recovery, liver transplantation is the most successful treatment for most cases.