肝移植中边缘供体使用经验的初步探讨

目的:探讨肝移植中使用边缘供肝〔包括脂肪供肝、寄生虫供肝、HCV(+)供肝和HBsAg(+)供肝〕对术后肝功能和预后的影响。方法:分析中山大学附属第一医院近5年采用UW液体灌注供肝的首次肝移植患者85例的临床资料。其中边缘供肝44例（35例脂肪肝, 6例寄生虫肝, 2例乙肝, 1例丙肝）, 正常供肝41例(对照组)。35例脂肪肝供肝依据脂肪变性程度分3组, 分别比较各组肝移植术后当天,术后1,2,3,7 d血清谷丙转氨酶(ALT)、谷草转氨酶(AST)、总胆红素（TB）水平、凝血酶原时间（PT）、ICU 时间、迟发性无功能（DNF）发生率和3, 6个月患者生存率等指标。对6例寄生虫供肝术后行B超严密观察, 对1例HCV(+)和2例HBSAg(+)供肝受体术后血清检测及其对预后影响进行分析。结果:脂肪变≥40%组的术后ALT, AST, TB, PT均高于脂肪变20%～40%组（P＜0.05）； 脂肪变20%～40%组术后AST, ALT, TB均高于脂肪变＜20%组（P＜0.05）； 供肝脂肪变＜20%组与对照组比较差异无显著性； 脂肪肝供肝各组术后迟发性无功能发生率和3,6个月存活率均无统计学差异。寄生虫供肝、HCV(+)及HBV(+)供肝未增加术后病死率。结论:供肝脂肪变＜20%者作为供肝较安全； 随着供肝脂肪变性程度的加重, 移植术后肝衰竭风险增大； 对脂肪变≥40%供肝应慎重或避免使用。在没有合适供肝的紧急情况下, 可考虑使用寄生虫供肝、HCV(+)和HBV(+)供肝。

Application of the marginal donor liver in orthotopic liver transplantation: A single-center experience

Abstract:Objective:To evaluate the safety of using so-called “marginal donors liver (MDL)” in liver transplantation, that included livers with steatosis, parasitic infestation,HCV(+) and HBsAg(+). Methods :The clinical data of 85 cases of primary liver transplantation in our hospital were retrospectively analyzed. Among the donor livers, 44 were MDL including 35 livers with steatosis, 6 with parasitic infection, 2 with HBsAg(+), I with HCV(+). Of the 35 livers with steatosis, the grafts were divided into 3 subgroups based on the degree of fatty infiltration. Liver function parameters including AST, ALT, TB, PT on the day of surgery and 1,2,3,7 days after surgery were monitored among the 3 sub groups, as well as the incidence of delayed nonfunction (DNF), and 3 and 6 months patient survival rate. Six hepatic graft with parasite,1 with HCV(+) and 2 with HBsAg(+) were also closely monitored as above.Results:There were significant difference in postoperative ALT、AST、TB、PT between hepatic steatosis≥40％ group and 20％~40% group, and between hepatic steatosis 20％~40% group and＜20% group. There was no significant difference among the groups in DNF occurrence rate and 3 month, 6 month patient survival rate in the 3 groups. Correlation analysis suggested that the degree of donor liver with steatosis was positively correlated with the damage of liver function after transplation. The use of HCV(+) and HBV(+) grafts did not lead to an increased mortality.Conclusions:Grafts with ≥20％ steatosis are relatively safe donors. As the degree of severity of steatosis increases, the risk of post-transplantation liver failure is increased. Grafts with ≥40％ steatosis should be more carefully used or avoided as far as possible, expect in emergency because the higher the degree of graft steatosis the more serious is damage of postoperative liver function. The use of an HBsAg (+) and HCV (+) cadaveric liver graft and hepatic graft with parasite may be considered when no other donor is available.