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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

陈晨, 杨润, 冯俊琦, 等. 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[J]. 器官移植, 2022, 13(2): 219-224. doi: 10.3969/j.issn.1674-7445.2022.02.010
引用本文: 陈晨, 杨润, 冯俊琦, 等. 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[J]. 器官移植, 2022, 13(2): 219-224. doi: 10.3969/j.issn.1674-7445.2022.02.010
Chen Chen, Yang Run, Feng Junqi, et al. Relationship between the incidence of acute kidney injury and postoperative changes of coagulation function in adult recipients after liver transplantation[J]. ORGAN TRANSPLANTATION, 2022, 13(2): 219-224. doi: 10.3969/j.issn.1674-7445.2022.02.010
Citation: Chen Chen, Yang Run, Feng Junqi, et al. Relationship between the incidence of acute kidney injury and postoperative changes of coagulation function in adult recipients after liver transplantation[J]. ORGAN TRANSPLANTATION, 2022, 13(2): 219-224. doi: 10.3969/j.issn.1674-7445.2022.02.010

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

doi: 10.3969/j.issn.1674-7445.2022.02.010
基金项目: 

国家自然科学基金面上项目 81873590

详细信息
    作者简介:
    通讯作者:

    邓羽霄,男,1976年生,主任医师,硕士研究生导师,研究方向为重症肝衰竭及肝移植围手术期管理,Email:denyuxiao@renji.com

  • 中图分类号: R617, R331

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

More Information
  • 摘要:   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。

     

  • 表  1  两组受者围手术期指标的比较

    Table  1.   Comparison of perioperative indicators of recipients between the two groups

    指标 非AKI组(n=146) AKI组(n=99) P
    术前指标
      肝性脑病[n(%)] 7(5) 7(7) 0.088
      ALT[M(P25P75),U/L] 38(24,59) 39(24,85) 0.664
      AST[M(P25P75),U/L] 49(34,108) 52(37,116) 0.632
      TB[M(P25P75),μmol/L] 46(21,217) 44(21,352) 0.576
      白蛋白[M(P25P75),g/L] 35(32,41) 36(32,39) 0.654
      PT-INR[M(P25P75)] 1.3(1.1,1.7) 1.3(1.1,1.7) 0.613
      D-二聚体[M(P25P75),mg/L] 0.9(0.5,2.1) 1.0(0.3,1.9) 0.842
      FDP[M(P25P75),mg/L] 6(2,14) 6(2,11) 0.856
      血小板计数[M(P25P75),×109/L] 67(47,120) 75(46,116) 0.823
      血清肌酐[M(P25P75),μmol/L] 64(52,79) 72(57,87) 0.003
      血红蛋白[M(P25P75),g/L] 104(83,125) 116(89,142) 0.051
      腹腔积液[M(P25P75),mL] 200(0,1 575) 0(0,1 000) 0.146
    术中指标
      失血量[M(P25P75),mL] 600(400,1 000) 800(400,1 000) 0.330
    输血量
       红细胞[M(P25P75),U] 4(0,8) 4(2,8) 0.096
       血浆[M(P25P75),mL] 400(0,1 000) 600(0,1 000) 0.195
    术后指标
      住院病死率[n(%)] 2(1) 17(17) < 0.001
    下载: 导出CSV

    表  2  两组受者术后24 h内肝功能及凝血指标的比较

    Table  2.   Comparison of liver function and coagulation index of recipients between two groups within 24 h after operation [M(P25, P75)]

    指标 非AKI组(n=146) AKI组(n=99) P
    ALT(U/L) 480(279,808) 678(271,1 160) 0.045
    AST(U/L) 835(406,1 615) 1 645(576,3 696) < 0.001
    TB(μmol/L) 71(41,123) 91(50,200) 0.029
    血小板计数(×109/L) 53(31,88) 47(27,72) 0.232
    血小板聚集率(%) 35(18,58) 31(12,52) 0.248
    血小板聚集率(%) 30(12,64) 30(6,56) 0.164
    凝血因子Ⅱ 0.39(0.29,0.52) 0.35(0.29,0.50) 0.214
    凝血因子Ⅴ 0.35(0.25,0.56) 0.26(0.15,0.41) < 0.001
    凝血因子Ⅶ 0.52(0.35,0.67) 0.43(0.31,0.57) 0.007
    凝血因子Ⅷ 1.41(1.02,1.92) 1.37(0.92,1.81) 0.271
    凝血因子Ⅸ 0.52(0.42,0.76) 0.48(0.34,0.62) 0.011
    凝血因子Ⅹ 0.45(0.33,0.57) 0.38(0.28,0.51) 0.021
    凝血因子Ⅺ 0.33(0.24,0.50) 0.32(0.22,0.44) 0.281
    凝血因子Ⅻ 0.23(0.19,0.33) 0.21(0.17,0.27) 0.005
    蛋白S(%) 32(19,43) 26(13,35) 0.017
    蛋白C(%) 44(35,61) 40(32,53) 0.048
    抗凝血酶Ⅲ(%) 40(31,56) 35(25,45) < 0.001
    PT-INR 1.5(1.3,1.8) 1.7(1.5,2.2) < 0.001
    D-二聚体(mg/L) 1.8(0.9,3.1) 2.8(1.5,7.7) < 0.001
    FDP(mg/L) 12(7,22) 19(12,35) < 0.001
    FIB(g/L) 1.7(1.3,2.3) 1.4(1.0,1.9) < 0.001
    注:①为二磷酸腺苷诱导的血小板聚集。
    ②为花生四烯酸诱导的血小板聚集。
    下载: 导出CSV

    表  3  两组受者术后24 h内血栓弹力图指标的比较

    Table  3.   Comparison of thrombelastogram indexes of recipients between two groups within 24 h after operation [M(P25, P75)]

    项目 非AKI组(n=146) AKI组(n=99) P
    R值(min) 7(6,8) 8(6,9) 0.001
    K值(min) 4.0(2.3,6.5) 5.0(3.0,7.8) 0.056
    α角(°) 61(53,68) 57(50,64) 0.019
    MA(mm) 41(33,53) 40(34,48) 0.344
    LY30(%) 0(0,0) 0(0,0) 0.376
    凝固时间(min) 29(27,31) 30(27,35) 0.005
    血块强度(d/sc) 3 534(2 475,5 563) 3 159(2 344,4 496) 0.118
    下载: 导出CSV
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  • 收稿日期:  2021-11-25
  • 网络出版日期:  2022-03-18
  • 刊出日期:  2022-03-15

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