非生物型人工肝治疗肝衰竭的疗效评价
Evaluation on Efficacy of Non-biological Artificial Liver in Treatment of Liver Failure
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摘要: 目的 探讨不同类型的非生物型人工肝支持系统对肝功能衰竭的疗效.方法 选取2014年1月至2015年1月在昆明市第三人民医院住院的肝功能衰竭患者106例, 共行人工肝治疗240人次, 按照人工肝类型分为2组, 血浆置换 (plasma exchange, PE) 组62例, 血浆置换联合血液透析滤过 (plasma exchange+hemodiafiltration, PE+HDF) 组44例, 记录人工肝治疗前后患者实验室指标及终末期肝病模型 (MELD) 评分, 评价2组的治疗效果.结果 (1) 2组治疗后血清总胆红素 (TBIL) 、门冬氨酸氨基转移酶 (AST) 、丙氨酸氨基转移酶 (ALT) 、总胆汁酸 (TBA) 水平均有明显降低, 差异有统计学意义 (P<0.05) ; (2) 人工肝治疗后总胆红素、胆汁酸清除率等于1-治疗后/治疗前, 与PE组相比, PE+HDF组对总胆红素、胆汁酸清除率更高, 差异有统计学意义 (P<0.05) ;PE组治疗后总胆红素、胆汁酸清除率分别为 (54.07±11.03) %, (85.95±30.22) %, PE+HDF组治疗后总胆红素、胆汁酸清除率分别为 (63.03±11.15) %, (92.40±40.13) %; (3) PE组、PE+HDF组治疗后凝血酶原活动度 (PTA) 指标明显上升, 并且国际标准化比值 (INR) 下降, 各组中PTA和INR治疗前后差异均有统计学意义 (P<0.05) , 提示2种模式对凝血功能均有明显改善作用; (4) 与PE组相比, PE+HDF组对PTA的提升效果更好, 差异有统计学意义 (P<0.05) ;PE组治疗后PTA提高 (88±65%) , PE+HDF组治疗后PTA提高 (102±73) %. (5) 比较2组治疗前后血氨的改变, PE组治疗后血氨无改善;PE+HDF组治疗后血氨明显下降, 血氨治疗前后差异有统计学意义 (P<0.05) ; (6) PE组治疗后肾功能较治疗前损伤加重, 可升高血钠、降低血钾, 差异有统计学意义 (P<0.05) ;PE+HDF组治疗后可以改善肾功能、纠正低钠血症及高钾血症, 差异有统计学意义 (P<0.05) ; (7) 2组治疗后终末期肝病模型 (MELD) 评分均下降, 且各组治疗前后的差异均具有统计学意义 (P<0.05) ;与PE组相比, PE+HDF组对终末期肝病模型评分改善更好, 差异有统计学意义 (P<0.05) .结论 相对血浆置换来说, 血浆置换联合血液透析滤过可以增加对白蛋白结合性毒素 (总胆红素、胆汁酸) 的清除, 对凝血酶原活动度的提升效果更佳, 增加中、小分子的清除, 更有效治疗肝衰竭合并肝性脑病、肝肾综合征、内环境紊乱等患者;血浆置换和血浆置换联合血液透析滤过对终末期肝病模型评分有明显改善作用, 均降低死亡风险及改善预后, 以血浆置换联合血液透析滤过组更好.Abstract: Objective To explore the efficacy of different non-biological artificial liver supporting system on liver function failure by retrospective study.Methods One hundred and six patients with liver failure were selected, who were diagnosed in the Third People's Hospital of Kunming City from January, 2014 to January, 2015, and during this period 240 person-time of the artificial liver treatment were completed.The patients weredivided into two groups according to the types of artificial liver, 62 patients in plasma exchange group (referred as PE) , 44 patients in plasma exchange combined with hemodiafiltration group (referred as PE+HDF) .Before and after the artificial liver treatment, we recorded the artificial liver laboratory indexes of the patients and model for end-stage liver disease (MELD) score, so as to evaluate the efficacy of two groups of treatment.Results (1) For these two groups, after treatment, the serum total bilirubin (TBIL) , aspartate aminotransferase (AST) , alanine aminotransferase (ALT) , total bile acid (TBA) levels were significantly reduced, and the difference was statistically significant (P<0.05) ; (2) Total bilirubin and bile acid clearance rate after artificial liver treatment was equal to 1-after treatment before treatment, compared with the group of PE, total bilirubin and bile acid clearance rate of PE+HDF group was higher, and the difference was statistically significant (P<0.05) .After PE treatment, the clearance rates of total bilirubin and bile acid were 54.07±11.03% and 85.95±30.22% respectively;after PE+HDF treatment, the clearance rates of total bilirubin and bile acid were 63.03±11.15% and 92.40 ±40.13% respectively; (3) After treatment, prothrombin activity (PTA) index significantly increased and International Normalized Ratio (INR) value decreased both in PE group and PE+HDF group, and the difference of PTA and INR before and after treatment in each group was statistically significant (P<0.05) , suggesting that both the two models had significant effects on improving the coagulation function; (4) Compared with the group of PE, the promotion of the PTA in PE+HDF group was better, and the difference was statistically significant (P<0.05) ;The PTA increased by 88±65% in group PE while increased by 102±73% in PE+HDF group; (5) By comparing the changes of blood ammonia before and after treatment between the two groups, blood ammonia had no improvement after treatment in group HE;And blood ammonia dropped significantly after treatment in PE+HDF group, with the statistically significant difference before and after ammonia treatment (P<0.05) .Blood ammonia decreased by 50.58±23.58% after treatment in group PE+HDF; (6) Renal function was damaged after treatment compared with that before treatment in PE group, which could cause the serum sodium to increase and serum potassium to decrease, with the statistically significant difference (P<0.05) ;In group PE+HDF, the treatment could improve the renal function and correct hyponatremia and hyperkalemia, with statistically significant difference (P<0.05) ; (7) Model for end-stage liver disease (MELD) score decreased after treatment both in HE group and PE+HDF group, and the differences of each group before and after treatment were statistically significant (P<0.05) ;Compared with the group of PE, PE+HDF group improved more in the end-stage liver disease score, and the difference was statistically significant (P <0.05) .Conclusion Compared with plasma exchange, plasma exchange combined with hemodiafiltration can increase the removal of albumin bound toxins (total bilirubin and bile acid) , is more effective in ptomoting prothrombin activity, and increasing the clearance of small and middle molecules so that the treatment is more effective on patients with liver failure complicated with hepatic encephalopathy, liver and kidney syndrome and internal environment disorder, etc;Both plasma exchange and plasma exchange combined with hemodiafiltration can significantly improve the model of end-stage liver disease, and reduce the risk of death and improve prognosis, but plasma exchange combined with hemodiafiltration is better.
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Key words:
- Artificial liver /
- Liver failure /
- Efficacy evaluation
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