成人肝移植术后急性肾损伤的发生与术后凝血功能变化的关系

目的  探讨肝移植术后凝血功能改变对急性肾损伤(AKI)发生的影响。方法  回顾性分析符合纳入和排除标准的245例肝移植受者的临床资料，根据肝移植术后是否发生AKI，将受者分为AKI组(99例)和非AKI组(146例)，总结肝移植术后AKI的发生情况，并收集受者的围手术期指标，对肝移植受者术后发生AKI的危险因素进行单因素和多因素分析。结果  245例肝移植受者中，99例术后发生了AKI，发生率为40.4%。AKI组受者术前血清肌酐水平较高，住院病死率较高(均为P < 0.05)。与非AKI组受者比较，AKI组受者术后24 h内肝功能指标升高更明显; Ⅱ期凝血指标凝血因子Ⅴ、Ⅶ、Ⅸ、Ⅹ、Ⅻ，蛋白S，蛋白C，抗凝血酶Ⅲ水平降低，凝血酶原时间国际标准化比值(PT-INR)升高; Ⅲ期凝血指标D-二聚体、纤维蛋白原降解产物(FDP)水平升高更明显，纤维蛋白原(FIB)水平降低(均为P < 0.05)。血栓弹力图结果显示，AKI组受者R值增大、α角减小、凝固时间延长(均为P < 0.05)。logistic回归分析结果显示，术后血栓弹力图R值增大[比值比(OR)1.116，95%可信区间(CI)1.018~1.223，P=0.019]，抗凝血酶Ⅲ水平降低(OR 0.974，95%CI 0.955~0.993，P=0.007)是肝移植术后发生AKI的独立危险因素。结论  肝移植术后AKI的发生率高，与受者凝血功能改变相关，凝血因子活性下降(R值增大)、抗凝血酶Ⅲ水平降低是肝移植受者发生AKI的独立危险因素。

Relationship between the incidence of acute kidney injury and postoperative changes of coagulation function in adult recipients after liver transplantation

Objective To evaluate the effect of coagulation function changes on the incidence of acute kidney injury(AKI)after liver transplantation.Methods Clinical data of 245 liver transplant recipients who met the inclusion and exclusion criteria were retrospectively analyzed.According to the incidence of AKI after liver transplantation,all recipients were divided into the AKI group(n=99)and non-AKI group(n=146).The incidence of AKI after liver transplantation was summarized.Perioperative parameters of the recipients were collected.The risk factors of AKI after liver transplantation were assessed by univariate and multivariate analysis.Results Among 245 recipients undergoing liver transplantation,99 cases developed AKI after operation with an incidence rate of 40.4%.Preoperative serum creatinine levels of the recipients and the in-hospital fatality were relatively high in the AKI group(all P<0.05).Compared with the recipients in the non-AKI group,those in the AKI group presented with significantly higher liver function parameters within postoperative 24 h,significantly decreased levels of stageⅡcoagulation parameters including coagulation factorsⅤ,Ⅶ,Ⅸ,Ⅹ,Ⅻand protein S,protein C and antithrombinⅢ,evidently elevated prothrombin time international normalized ratio(PT-INR),remarkably increased stageⅢcoagulation parameters including D-dimer and fibrin degradation product(FDP)levels and considerably decreased fibrinogen(FIB)level(all P<0.05).Thrombelastogram showed that the R value was increased,theαangle was decreased and the coagulation time was prolonged in the AKI group(all P<0.05).Logistic regression analysis demonstrated that the increased R value of postoperative thrombelastogram[odd ratio(OR)1.116,95%confidence interval(CI)1.018-1.223,P=0.019],and decreased levels of antithrombinⅢ(OR 0.974,95%CI 0.955-0.993,P=0.007)were the independent risk factors of incidence of AKI after liver transplantation.Conclusions The incidence of AKI after liver transplantation is high,which is associated with the coagulation function changes of the recipients.Decreased coagulation factor activity(increased R value)and declined antithrombinⅢlevel are the independent risk factors of AKI in liver transplantat recipients.