[肝移植术后中枢性桥脑髓鞘溶解症的可能病因]

Yu Jun, Liang Ting-bo, Zheng Shu-sen, Shen Yan, Wang Wei-lin, Ke Qing-hong

Department of Hepatobiliary Pancreatic Surgery, the First Affiliated Hospital, Medical School of Zhejiang University, Hangzhou 310003, China.

Zhonghua Wai Ke Za Zhi. 2004 Sep 7;42(17):1048-51.

OBJECTIVE

To sum up the clinical characteristics of patients with central pontine myelinolysis (CPM) after orthotopic liver transplantation (OLT) and to document the possible causes on CPM.

METHODS

142 patients' data with OLT between January 1999 to May 2003 were analyzed retrospectively. The following risk factors during preoperation were analyzed between patients with and without CPM: primary liver disease, preoperative serum sodium level, magnesium level and plasma osmolality, fluctuation degree of serum sodium concentration, and immunosuppressive drugs level etc.

RESULTS

A total of 13 (9.2%) neurologic symptoms appeared in 142 patients post operation, including 5 cases (3.5%) with CPM and 8 cases (5.6%) with cerebral hemorrhage or infarct. 2 patients who developed CPM after OLT had hyponatremia history before operation (serum sodium <130 mmol/L), and the mean serum sodium level was (130.6 +/- 5.54) mmol/L. The serum sodium level was significantly lower in CPM than that of patients without neurologic complication or with cerebral hemorrhage/infarct (P <0.05). The rises of serum sodium perioperative 48 h after OLT in patients with CPM was significantly greater than that in patients with cerebral hemorrhage/infarct or no neurologic complication (19.5 +/- 6.54) mmol/L, (10.1 +/- 6.43) mmol/L, (4.5 +/- 4.34) mmol/L, respectively, (P < 0.05). Plasma osmolality increased greatly postoperatively in patients with CPM. Hypomagnesemia was noted in all patients perioperatively, but there was not significant difference among groups. The duration of operation in CPM was longer than in others (492 +/- 190.05) min (P <0.05). Cyclosporin A (CsA) levels were normal in all patients, but there was significant difference between patients with and without neurologic complication (P <0.05).

CONCLUSIONS

CPM may be more prevalent following liver transplantation. Although the diagnosis of CPM after OLT can be made by complete neurologic evaluation including magnetic resonance imaging (MRI) of the head, the mortality is still very high. The occurrence of CPM may be associated with hyponatremia, rapid rise of serum sodium concentration, postoperative increase of plasma osmolality, the duration of operation and high CsA levels.

目的

总结原位肝移植（OLT）术后发生中枢性脑桥髓鞘溶解症（CPM）患者的临床特征，并探讨CPM可能的发病原因。

方法

回顾性分析1999年1月至2003年5月间142例行OLT患者的数据。分析发生CPM与未发生CPM患者术前的以下危险因素：原发性肝病、术前血清钠水平、镁水平、血浆渗透压、血清钠浓度波动程度及免疫抑制药物水平等。

结果

142例患者术后共出现13例（9.2%）神经症状，其中CPM 5例（3.5%），脑出血或脑梗死8例（5.6%）。2例OLT术后发生CPM的患者术前有低钠血症病史（血清钠<130 mmol/L），平均血清钠水平为（130.6±5.54）mmol/L。CPM患者的血清钠水平显著低于无神经并发症或脑出血/梗死患者（P<0.05）。CPM患者OLT术后48 h内血清钠升高幅度显著大于脑出血/梗死患者及无神经并发症患者，分别为（19.5±6.54）mmol/L、（10.1±6.43）mmol/L、（4.5±4.34）mmol/L（P<0.05）。CPM患者术后血浆渗透压大幅升高。所有患者围手术期均有低镁血症，但各组间无显著差异。CPM患者手术时间长于其他患者（492±190.05）min（P<0.05）。所有患者环孢素A（CsA）水平均正常，但有神经并发症与无神经并发症患者之间存在显著差异（P<0.05）。