急诊成人活体右半肝肝移植治疗重型肝炎肝功能衰竭的临床研究

目的 探讨急诊成人活体右半肝肝移植在治疗重型肝炎肝功能衰竭中的作用.方法 2007年4至12月接受活体肝移植患者中,共有10例接受了急诊活体肝移植治疗(4例为慢性重型肝炎、6例为急性肝功能衰竭;9例为乙型肝炎、1例为药物性肝功能衰竭).终末期肝病模型(MELD)评分平均为33.22±6.55.ABO血型相同者8例,相容者2例,Rh不相容者1例.对术后的相关指标进行前瞻性分析.结果 1例术后发生腔静脉血栓形成致急性肾功能衰竭死亡,另1例发生肝动脉血栓形成致移植物失功能而死亡,余受者和所有供者均恢复良好,受者随访6～14个月,中位生存已达8.5个月,均无并发症发生.平均移植物重量和受者体重比值为(1.19±0.14)%,移植物容积和受者估计标准肝容积比为(65.13±8.75)%;带肝中静脉右半肝移植物3例,不带肝中静脉右半肝合并Ⅴ段和Ⅷ段流出道重建3例,不带肝中静脉右半肝4例.术后血清肌酐、内毒素水平、凝血酶原活动度及总胆红素分别在术后第3、7、14、28天恢复到正常水平.结论 急诊成人活体右半肝肝移植治疗重型肝炎肝功能衰竭效果满意,作为重型肝炎肝功能衰竭的抢救治疗疗效确切.     

人工肝支持系统联合肝移植治疗晚期重型肝炎的临床经验

目的总结人工肝支持系统 (artificialliversupportsystem ,ALSS)联合肝移植治疗晚期重型肝炎患者的临床经验。方法我院 1993年 4月至 2 0 0 3年 12月共实施 2 2 3例原位肝移植 ,其中 2 3例晚期重型肝炎患者在移植前共进行了 5 8例次的ALSS治疗 ,现就其临床诊治资料进行回顾性分析 ,并与常规内科治疗组、未施行肝移植的单纯ALSS治疗组疗效进行比较。结果ALSS治疗后患者临床症状好转 ,肝功能、内毒素等各项实验室指标显著改善 ,能维持的中位时间为 12d( 2～ 2 2 6d) ;2 3例患者实施肝移植 ,移植术前血清总胆红素 (TB)水平显著低于患者首次ALSS治疗前水平 (P <0 0 0 1) ;自首次ALSS治疗日计算 ,该组患者等待供肝的中位时间为 12d( 2～ 2 2 6d) ,本组晚期重型肝炎患者半年存活率达 73 9% ,显著高于常规内科治疗组和未施行肝移植的ALSS治疗组 (P <0 0 0 1)。结论ALSS能显著改善晚期重型肝炎病情 ,发挥顺利过渡到肝移植的桥梁作用     

非生物型人工肝在肝移植中的应用九例

目的评价非生物人工肝对慢性乙型重症肝炎患者等待肝移植的过渡支持作用。方法采用非生物型人工肝血浆置换方法对9例急需进行肝移植的慢性乙型重症肝炎患者进行人工肝支持治疗,以纠正内环境紊乱,使患者顺利度过待肝期。结果非生物人工肝治疗后,9例患者的胆红素总量和胆汁酸总量明显低于治疗前(P<0.01),凝血酶原活动度、胆固醇总量、胆碱脂酶及前白蛋白明显高于治疗前(P<0.01)。9例等待供肝时间为7~10d,均成功接受肝移植。随访至今,存活7例,存活时间最长者已达1年,2例分别于肝移植术后4、5d死亡。结论非生物型人工肝对等待肝移植的慢性重症肝炎患者有一定的过渡支持作用。     

Effect of Intervention Therapy Based on Liver-spleen Correlation Theory on Intestinal Mucosal Barrier Function in Patients with Chronic Severe Hepatitis

[目的]观察应用肝脾相关理论干预慢性重型肝炎的临床疗效及探讨其对肠黏膜屏障的保护作用.[方法]选取慢性重型肝炎患者60例,采用简单随机法将患者随机分为对照组(基础治疗+凉血解毒法)30例和观察组(基础治疗+凉血解毒法+健脾益气法)30例,疗程2周,共2个疗程,观察治疗前后症状积分、血清学变化和治疗后总有效率,同时观察2组患者的肠黏膜通透性(血清二胺氧化酶水平、尿中乳果糖/甘露醇排出率)和血浆内毒素水平.[结果]观察组的总有效率(80.0％)优于对照组(66.7％),差异有显著性意义(P＜0.05).2组均可改善临床症状,改善肝功能,升高凝血酶原活动度,且观察组作用优于对照组,差异有显著性意义(P＜0.05);2组治疗前内毒素水平、尿中乳果糖/甘露醇排出率比较,差异均无显著性意义(P＞0.05),治疗后观察组血浆内毒素水平、尿中乳果糖/甘露醇排出率较治疗前显著降低(P＜0.05),且与对照组比较差异有显著性意义(P＜0.05).[结论]应用肝脾相关理论治疗慢性重型肝炎可提高临床疗效,并可改善慢性重型肝炎患者肠黏膜屏障功能,纠正肠源性内毒素血症.     

重型肝炎肝移植术后急性肾功能衰竭的防治

目的 总结重型肝炎肝移植术后急性肾功能衰竭（ARF）的防治经验。方法 回顾性分析2002年9月至2004年10月上海交通大学医学院附属瑞金医院因重型肝炎行肝移植治疗的37例病人的临床资料。结果 37例病人术后1年移植物存活率为83.8％，围手术期死亡6例（16．2％），术后并发ARF12例（32．4％），ARF组与非ARF组术前血总胆红素、肌酐、腹水量、凝血酶原时间比较，差异有显著性意义；两组术中出血量、血制品输入量、无肝期、手术时间比较，差异亦有显著性意义。结论 重型肝炎肝移植术后ARF诱发因素众多，多数病人经过综合治疗后肾功能能够得到恢复，必要时可选择连续性肾替代治疗（CRRT）。     

人工生物肝治疗重症急性肝衰(英)

临床证明原位肝移植是治疗重症急性肝衰的唯一有效方法．但许多病人在得到器官以前即死亡。因此，这些病人在获取器官之前迫切需要一种肝支持系统以帮助维持病人的生命和神经功能。为治疗重症急性肝衰，作者根据血浆灌注的原理．通过一循环式中空纤维管，将猪肝细胞用基质固定种植于管内，制备了人工生物肝脏(BAL)本文总结7例重症急性肝衰11例次BAL作为肝移植前过渡治疗的初步临床经验。     

中药联合食醋保留灌肠治疗慢性重型肝炎效果观察

目的探讨中药联合食醋保留灌肠对治疗慢性重型肝炎的效果。方法将84例慢性重型肝炎患者按入院单双日分为观察组与对照组各42例。对照组采用综合支持、护肝治疗，观察纽在此基础上加用中药联合食醋保留灌肠。结果治疗后对照组与观察组ALT、TBIL、PT、PTA、血氨比较，差异有显著性意义（均P〈0．01）。治疗后观察组主要并发症如感染、肝肾综合征、肝性脑病的发生率显著低于对照组（均P＜0．05），而治疗效果显著优于对照组（P＜0．05）。结论中药联合食醋保留灌肠可改善慢性重型肝炎患者的肝功能。降低并发症发生率，疗效显著。     

肝移植治疗重型肝炎手术时机选择(附36例分析)

目的 重型肝炎肝移植手术时机选择.方法 用原位肝移植联合人工肝技术治疗重型肝炎36例.结果 ①MELD评分＜30组与≥30分2组患者1年存活率有明显差异(77.8%和33.3%,P＝0.007).②MELD评分＜30分组肝移植病人的并发症发生率明显低于≥30分组(P＝0.012).③MELD评分＜30组与≥30分2组病人人工肝使用次数、手术持续时间、出血量、输血量、住院费用进行t检验没有统计学差异.但MELD评分≥30组的日均住院费用明显高于＜30组(P＝0.008).结论 MELD评分＜30分肝移植预后明显好于≥30分的重型肝炎患者.     

生物人工肝构建及临床应用14例次报告

目的　研究用聚砜膜纤维管构建的新型生物人工肝是否能有效支持肝脏功能。方法应用两步胶原酶法分离猪肝细胞 ,构建聚砜膜中空纤维管生物反应器 ,细胞数量 1× 10 10 个 ,与非生物人工肝同期或非同期使用 ,对 12例患者治疗 14例次 ,每次支持时间为 6h ,治疗前后观察患者一般状况并检测血氨、凝血酶原时间和部分肝功能指标。结果　应用生物人工肝治疗后血氨、凝血酶原时间和总胆红素均明显改善 ,治疗 2d后血氨仍为 (10 6± 131) μmol/L ,与治疗前相比较 [(172± 187)μmol/L]差异有显著意义 (P <0 0 5 ) ;治疗后 1个月 ,同期生物人工肝治疗组死亡 1例 ,非同期生物人工肝治疗组死亡 2例 ,患者总存活率 75 % (9/12 )。结论　我们构建的新型生物人工肝可支持急性肝功能衰竭患者的肝功能 ,同期生物人工肝治疗可能优于非同期生物人工肝。     

人工肝支持系统治疗重型肝炎的疗效观察

人工肝支持系统是一种能替代正常肝脏的部分或全部功能的体外装置 ,用于治疗各种严重肝病。可提高重型肝炎的治愈率或缓解病情[1] ,为病人肝移植打下较好的基础。我科 1 999年 1 2月至 2 0 0 1年1 1月对 5 0例重型肝炎病人在药物治疗的基础上行人工肝血浆置换术 ,取得较好效果 ,报告如下。1　资料与方法1 .1　一般资料5 0例病人中 ,男 45例 ,女 5例 ,年龄 1 7～ 65岁 ,平均 35 .6岁。急性、亚急性重型肝炎 (戊型、乙型各 2例 ) 4例 ,慢性乙型肝炎合并戊型肝炎病毒重叠感染 3例 ,慢性重症型乙型肝炎 43例 ;5 0例中 ～ 级肝性脑病 5例。均符…     

Bioartificial liver inoculated with porcine hepatocyte spheroids for treatment of canine acute liver failure model

The aim of this study was to evaluate a novel bioartificial system in a canine model of acute liver failure. An acute liver failure model in canines was induced by an end-side portocaval shunt combined with common bile duct ligation and transection. The bioartificial liver system, which utilized blood perfusion through a hollow fiber bioreactor from BIOLIV A3A inoculated with 1.0 - 3.1 x 1010 porcine hepatocyte spheroids, was developed for the treatment of acute liver failure. Sixteen acute liver failure model canines were divided between a group treated with bioartificial liver (n=8) and a control group (n=8) for 5 h. Blood alanine aminotransferase (ALT), alkaline phosphatase (AKP), total bilirubin (TBi), direct bilirubin (DBi), prothrombin time (PT), ammonia levels, and the ratio of branched chain to aromatic amino acids (Fischer's ratio) were determined. ALT, AKP, TBi, DBi, and ammonia levels were significantly elevated, PT was significantly prolonged, and Fischer's ratio decreased significantly in the canine model of the two groups on day 14 after operation compared to baseline. There were no significant differences between the two groups in laboratory data before treatment. In canines treated with the bioartificial liver system, ALT, AKP, TBi, DBi, and ammonia levels decreased significantly, PT was significantly shortened, Fischer's ratio was significantly elevated after treatment, and the survival rate by day 7 after treatment was 100%. In canines in the control group, on the other hand, there were no significant differences in ALT, AKP, TBi, DBi, PT, and ammonia levels between pretreatment and posttreatment, though these indices decreased to a slight degree after treatment. The survival rate by day 7 after treatment was 62.5% in the control group. Fischer's ratio decreased after treatment. ALT, AKP, TBi, DBi, PT, and ammonia levels in the bioartificial liver system group were lower, and Fischer's ratio and survival rate were higher than those in the control group after treatment. These results indicate that the novel bioartificial liver system we developed has a significant impact on the course of canine acute liver failure model and has potential advantages for clinical use in patients with acute liver failure.     

生物人工肝系统治疗对急性肝衰竭犬血清内毒素的影响

目的　探讨生物人工肝 (BAL )系统治疗急性肝衰竭 (ALF )的效果及其与内毒素的关系。方法　采用门腔分流及胆总管结扎切断术建立犬ALF模型。 10只实验动物随机分为两组 ,即BAL治疗组和对照组 (未行BAL治疗组 )。BAL每次循环 5h。检测两组建模前 ,以及循环前后的血清内毒素、谷丙转氨酶 (ALT )和总胆红素 (TB)。结果　治疗组建模前、循环前和循环后血清内毒素分别为 0 .2 84EU /ml ,0 .5 2 6EU /ml ,0 .416EU /ml ;循环前血清内毒素较建模前明显升高 (P <0 .0 5 ) ,循环后又明显降低 (P <0 .0 5 ) ;对照组循环前血清内毒素显著高于建模前 (P <0 .0 5 ) ,循环前后血清内毒素无明显变化 (P >0 .0 5 )。治疗组循环后血清ALT和TB较循环前明显下降 (P <0 .0 5 ) ;对照组循环前后ALT和TB无明显变化 (P >0 .0 5 )。结论　BAL治疗能降低ALF犬血清内毒素含量。     

Internal bioartificial liver with xenogeneic hepatocytes prevents death from acute liver failure: an experimental study.

OBJECTIVE: To demonstrate that a bioartificial liver, using allogeneic or xenogeneic hepatocytes protected from rejection by a semipermeable membrane, could prevent death from acute liver failure. SUMMARY BACKGROUND DATA: An implantable bioartificial liver using isolated hepatocytes could be an alternative to orthotopic liver transplantation to treat patients with acute liver failure. It could serve either as a bridge until liver transplantation or as the main treatment until recovery of the native liver. However, allogeneic or xenogeneic hepatocytes that could be used in clinical applications are spontaneously rejected. METHODS: Acute liver failure was induced in rats by 95% liver resection. Twenty-five million hepatocytes harvested in rats (allogeneic) or guinea pigs (xenogeneic) were encapsulated in a semipermeable membrane to protect them from rejection. The hollow fibers containing hepatocytes were transplanted into the peritoneum of recipient rats. Survival rates were compared between rats transplanted or not with hepatocytes. RESULTS: In groups not transplanted with viable hepatocytes, 73% to 93% of rats died after 95% liver resection. The mortality rate was reduced to 39% in rats transplanted with allogeneic hepatocytes and 36% in rats transplanted with xenogeneic hepatocytes. The bioartificial liver could be removed 1 month after transplantation, when regeneration of the native liver was complete. Allogeneic and xenogeneic hepatocytes remained viable. CONCLUSIONS: The implantable bioartificial liver was able to prevent death in this model of acute liver failure. This could be an important step toward clinical application of the method.     

A bioartificial liver to treat severe acute liver failure.

OBJECTIVE: To test the safety and efficacy of a bioartificial liver support system in patients with severe acute liver failure. SUMMARY BACKGROUND DATA: The authors developed a bioartificial liver using porcine hepatocytes. The system was tested in vitro and shown to have differentiated liver functions (cytochrome P450 activity, synthesis of liver-specific proteins, bilirubin synthesis, and conjugation). When tested in vivo in experimental animals with liver failure, it gave substantial metabolic and hemodynamic support. METHODS: Seven patients with severe acute liver failure received a double lumen catheter in the saphenous vein; blood was removed, plasma was separated and perfused through a cartridge containing 4 to 6 x 10(9) porcine hepatocytes, and plasma and blood cells were reconstituted and reinfused. Each treatment lasted 6 to 7 hours. RESULTS: All patients tolerated the procedure(s) well, with neurologic improvement, decreased intracranial pressure (23.0 +/- 2.3 to 7.8 +/- 1.7 mm Hg; p < 0.005) associated with an increase in cerebral perfusion pressure, decreased plasma ammonia (163.3 +/- 21.3 to 112.2 +/- 9.8 microMoles/L; p < 0.01), and increased encephalopathy index (0.60 +/- 0.17 to 1.24 +/- 0.22; p < 0.03). All patients survived, had a liver transplant, and were discharged from the hospital. CONCLUSIONS: This bioartificial liver is safe and serves as an effective "bridge" to liver transplant in some patients.     

急性肾衰竭患者血清胆碱酯酶变化的意义

目的通过观察急性肾衰竭（ARF）患者血清胆碱酯酶（CHE）的变化，探讨血清CHE与ARF预后的关系，并分析其临床意义。方法将68例ARF患者分为存活组（A组）及死亡组（B组），检测其治疗前后血清CHE，并与40例肾功能正常的原发肾小球疾病患者（M组）和30例健康体检者（N组）比较。结果A组和B组患者血清CHE均较M组和N组降低；而M组与N组间无显著性差异；A组患者治疗后血清CHE恢复，与治疗前CHE相比差异有统计学意义；B组患者治疗后血清CHE持续降低。结论血清CHE可作为ARF的检测物之一，对ARF患者的病情监测和预后判断具有重要的临床意义。     

犬急性肝衰竭一种新模型的建立

目的 为进行生物人工肝治疗等研究制备一种新的犬急性肝衰竭模型。方法 采用一期门腔端-侧分流、胆总管切断结扎术制作模型。观察其生存情况、肝功能、血氨、Fischer比(支链氨基酸／芳香氨基酸，BCAA／AAA)，并观察模型肝脏病理变化。结果 模型犬于术后血氨、谷雨转氨酶(ALT)、碱性磷酸酶(ALP)、总胆红素(TB)逐渐升高，凝血酶原时间(PT)延长，Fischer比下降，于2周时最为明显；14d后随着时间的延长，动物逐渐死亡。肝脏病理检查显示典型的淤胆、汇管区炎症、肝细胞变性、坏死表现。结论 一期门腔端一侧分流、胆总管结扎切断术制作犬急性肝衰竭模型成功，该模型可望用于生物人工肝的研究。     

What Should We Expect From a Bioartificial Liver In Fulminant Hepatic Failure?

Fulminant hepatic failure is associated with high mortality. Liver transplantation is an effective therapy that improves survival, and because of donor organ shortage and urgency, a bioartificial liver could act as an effective bridge to liver transplantation in patients with fulminant hepatic failure. We discuss the place of the bioartificial liver in the treatment of other causes of liver failure.     

PDD法吲哚氰绿潴留试验评估肝硬化与肝癌肝功能的临床意义

目的 探讨脉动色素浓度测定(PDD)吲哚氰绿(ICG)潴留试验对于评价肝硬化与肝癌肝储备功能的临床价值.方法 选取89例肝炎肝硬化患者和40例原发性肝癌患者,以PDD法测定ICG 15 win潴留率(ICGR15)及常规临床指标CHE、PAB、ALB、PTA、TBA;比较ICGRl5与以上临床指标对肝功能评价的意义,并各指标进行相关性分析.结果 (1)ICGR15、CHE、TBA、ALB、PTA在Child-Pugh A、B、C级3组比较,差异均有统计学意义(F=40.975,13.397,27.448,9.544,20.421,P<0.05),PAB在B级与A级、C级与A级之间差异有统计学意义(F=16.627,P<0.05).(2)肝炎肝硬化患者ICGRl5和TBA随Child-Push分值(C-P值)增加而递增,PTA则递减;ICGR15分别在C-P值5分与7分,9分与10分比较,差异有统计学意义(F=12.635,P<0.05).(3)ICGR15值与常用临床指标作相关性分析得出,与ICGR15值相关性最好的为TBA(r=0.605),其次为PTA、CHE、PAB、ALB(r=-0.598,-0.565,-0.537,-0.424).结论 PDD法ICGRl5与常规临床指标存在良好相关性,且明显优于常规肝功能指标,CHE、TBA也能够客观地评价肝储备状况.     

益生菌应用于肝移植术后患者的临床意义

目的：探讨益生菌应用于肝移植术后患者的临床价值。方法：将肝移植术后患者55例分为益生菌组和对照组,患者术后均给予免疫抑制剂,而益生菌组加服双歧杆菌四联活菌片1周（思连康,1.5 g,3次/d）。于术前及术后第2,5,8天检测患者血清胆红素（TBIL）,丙氨酸转氨酶（ALT）,血清清蛋白（ALB）,前清蛋白（PA）水平,并观察和记录患者术后感染及胃肠道不良反应的发生情况。结果：TBIL和ALT水平两组在术前及术后第2天均无统计学差异（均P>0.05）,但益生菌组TBIL和ALT水平分别在术后第8,5天开始明显低于对照组（均P<0.05）;ALB和PA水平两组在术前及术后第2天均无统计学差异（均P>0.05）,而术后第5,8天益生菌组的两者水平均明显高于对照组（均P<0.05）;术后1周内益生菌组与对照组的感染率及不良反应发生率分别为41.38%和69.23%（P=0.038）,17.24%和42.31%（P=0.041）。结论：肝移植术后应用益生菌可以改善机体的营养状况,促进肝功能恢复,并减轻炎症反应、降低术后感染及胃肠道不良反应的发生率。