血浆置换联合血液透析滤过治疗肝衰竭的临床应用

目的观察血浆置换（PE）联合血液透析滤过（HDF）治疗肝衰竭的临床效果和预后。方法48例肝功能衰竭患者行PE＋HDF治疗182例次，采用间歇治疗模式，间隔1-3天，每次历时3-4h。结果PE＋HDF治疗后意识障碍好转，黄疸、乏力、恶心、呕吐、腹胀等症状明显缓解，食欲增加，尿量增多，短期存活率（30d）为72．9％（35／48例）；血压、血氧饱和度、白蛋白、白细胞、红细胞和血小板无显著变化（P〉0．05）；总胆红素、直接胆红素、总胆汁酸、血氨分别较治疗前下降28．8％、29．8％、44．8％、28．4％（尸值均〈0．01）；单次治疗后凝血酶原时间由治疗前的（23．70±0．56）秒缩短为（16．60±0．67）秒（P〈0．01），临床出血倾向明显减轻。4例急性肝衰竭患者（8．3％）治疗痊愈出院，10例（20．8％）成功过渡至肝移植，21例（43．8％）治疗后15-30天好转，13例（27．1％）在治疗2414天内死亡，死亡原因为多脏器功能衰竭和内脏出血。结论PE＋HDF治疗有助于抢救急、慢性肝衰竭患者，安全性好，近期疗效显著，可作为肝移植前的过渡手段。

Clinical application of plasma exchange combined with hemodiafiltration in patients with liver failure

Objective To observe the therapeutic efficacy and prognosis of plasma exchange combined with hemodiafiltration in patients with liver failure. Methods Forty-eight patients with liver failure were treated with plasma exchange combined with hemodiafiltration in a total of 182 sessions. Results After the treatment, their conscious became clearer, jaundice, fatigue, nausea, vomiting and abdominal distention improved significantly, and appetite and urinary excretion increased. Their short term survival rate within 30 days was 72.9% （35/48）. There were no significant changes in blood pressure, blood oxygen saturation, albumin, white blood cell, red blood cell and platelet after the treatment （P 〉 0.05）. Total bilirubin, direct bilirubin, total bile acids and blood ammonia decreased by 28.8%, 29.8%, 44.8% and 28.4%, respectively （P 〈 0.01）. Prothrombin time became shorter after a session of the treatment from 23.704-0.56 seconds to 16.604-0.67 seconds （P 〈 0.01）, in association with the improvement of hemorrhage tendency. Of the 48 cases we treated, 4 cases （8.3%） discharged from the hospital with full recovery from acute liver failure, 10 （20.8%） partially recovered so that liver transplantation became possible, 21 （43.8%） improved within 15-30 days after the treatment, and 13 （27.1%） died of multiple organ failure and internal organ hemorrhage within 2-14 days after the treatment. Conclusion Plasma exchange in combination with hemodiafiltration is a safe measure for emergent treatment of acute and chronic liver failure with better therapeutic efficacy in a short period of time, and can be used as a pre-operation measure before liver transplantation.