成人肝移植后发生持续性血小板减少的危险因素分析及其预防措施探讨

目的：分析肝移植术后持续性血小板减少的危险因素，探索减少该疾病发生的有效治疗手段。方法：回顾性分析在浙江大学医学院附属第一医院肝胆胰外科2009年1月—2012年6月期间接受肝移植手术并符合纳入标准的128例患者资料，对移植前脾脏体积、术前门静脉直径、术前胃左静脉直径、术前和术后血小板、术前和术后白细胞、术前总胆红素水平及终末期肝病模型评分等指标进行统计分析，筛选术后持续性血小板减少的独立危险因素。并且对在2012—2013年期间部分术前存在危险因素的患者行肝移植同期脾动脉缩窄术，分析其术后持续性血小板减少的发生率。结果：患者肝移植术前脾脏体积大于500 ml（P=0.012，OR=2.789， 95%可信区间：1.249～6.227）以及门静脉直径大于15 mm（P=0.017， OR=3.124， 95%可信区间：1.230～7.933）为术后持续性血小板减少的独立危险因素。行肝移植同期脾动脉缩窄术的6例患者中仅1例（16.7%）在术后表现为持续性血小板减少，而对照组48例中32例（66.7%）术后存在持续性血小板减少，两者间差异有统计学意义（P<0.05）。结论：患者肝移植术前脾脏体积大于500 ml以及门静脉直径大于15 mm可以作为肝移植术后持续性血小板减少的独立危险因素。肝移植手术同期行脾动脉缩窄术以控制脾脏体积作为肝移植术后持续性血小板减少的预防方法具有一定的临床效果。

Risk factors of persistent thrombocytopenia after adult liver transplantation and prophylactic measures

Objective： To investigate the risk factors associated with persistent thrombocytopenia after liver transplantation （LT）， and to explore effective measures for prevention. Methods： One hundred and twenty eight adult patients， who received liver transplantation in our hospital between January 2009 and June 2012 and met the inclusive criteria， were enrolled in the study. The clinical data were retrospectively analyzed， including pre-LT spleen volume， main portal vein size， coronary vein size， platelet and white blood cell levels， total bilirubin level and model of end stage liver disease score. The risk factors associated with persistent thrombocytopenia after LT were evaluated by logistic regression analysis. The effect of simultaneous splenic artery coarctation for high risk patients was evaluated with χ² test. Results： Logistic regression analysis showed that per-LT spleen volume larger than 500 ml （P=0.012， OR=2.789， 95%CI: 1.249-6.227） and portal vein size beyond 15 mm （P=0.017， OR=3.124， 95%CI: 1.230-7.933） were independent risk factors for persistent thrombocytopenia after LT. The incidence rate of persistent thrombocytopenia after LT in patients with or without simultaneous splenic artery coarctation were 16.7% （1/6） and 66.7% （32/48）， respectively（P<0.05）. Conclusion： Spleen volume larger than 500 ml and portal vein size beyond 15 mm are risk factors for persistent thrombocytopenia after LT. Simultaneous splenic artery coarctation may reduce the occurrence of persistent thrombocytopenia after LT．