Chung H S, Jung D H, Park C S
Department of Anesthesiology and Pain Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
Transplant Proc. 2013 Jan-Feb;45(1):236-40. doi: 10.1016/j.transproceed.2012.06.077.
Acute liver failure (ALF) is a rare and fatal disease with rapidly deteriorating clinical features. Many predictive models for ALF outcomes have been tested, but none have been adopted as definitive guidelines for prognosis because of inconsistencies in accuracy. Most prognostic models for ALF are based on preoperative patient conditions, thus ignoring various specific intraoperative features relevant to postoperative outcomes. We investigated whether intraoperative factors predicted short-term mortality due to ALF in living donor liver transplantations (LDLT).
We retrospectively collected intraoperative data, including surgical time, fluctuations in mean blood pressure (MBP) and heart rate, mean pulmonary arterial pressure (PAP), central venous pressure (CVP), urine output, laboratory data, oxygen indices (PaO(2)/FiO(2)), administered drugs, and transfusion of packed red blood cells (PRBCs) from 101 patients with ALF who underwent LDLT. After simple relationships of individual intraoperative variables with 1-month posttransplant mortality were analyzed, we examined potentially significant intraoperative variables (P < .10) by a multivariate adjustment process with preoperative indicators of ALF prognosis.
Intraoperative MBP fluctuations, first mean PAP and CVP, last oxygen index, administered calcium chloride, and PRBC transfusion showed individual associations with posttransplant mortality of ALF patients (P < .05). After multivariate adjustment, PRBC transfusion of ≥ 10 pints (odds ratio 4.73; 95% confidence interval [CI] 1.06-21.16) and MBP fluctuations (odds ratio 1.26; 95% CI 1.00-1.58) were identified to be independent predictors of 1-month posttransplant mortality, together with preoperative factors, including severe hepatic encephalopathy, and a Model for End-stage Liver Disease score ≥ 30 points (area under the curve 0.82, P < .001).
MBP fluctuations and large blood transfusions were intraoperative predictors of short-term mortality after LDLT due to ALF. Increased attention to intraoperative manifestations should provide valuable prognostic information for ALF.
急性肝衰竭（ALF）是一种罕见的致命疾病，临床特征迅速恶化。许多用于预测ALF预后的模型都经过了测试，但由于准确性不一致，尚无一个模型被采纳为明确的预后指南。大多数ALF预后模型基于术前患者状况，因此忽略了与术后结果相关的各种特定术中特征。我们研究了术中因素是否可预测活体肝移植（LDLT）中因ALF导致的短期死亡率。
我们回顾性收集了101例接受LDLT的ALF患者的术中数据，包括手术时间、平均血压（MBP）和心率波动、平均肺动脉压（PAP）、中心静脉压（CVP）、尿量、实验室数据、氧合指数（PaO₂/FiO₂）、使用的药物以及浓缩红细胞（PRBC）输注情况。在分析了各个术中变量与移植后1个月死亡率的简单关系后，我们通过对ALF预后的术前指标进行多变量调整过程，检验了潜在的显著术中变量（P < 0.10）。
术中MBP波动、首个平均PAP和CVP、末次氧合指数、使用氯化钙以及PRBC输注与ALF患者移植后死亡率存在个体相关性（P < 0.05）。多变量调整后，≥10品脱的PRBC输注（比值比4.73；95%置信区间[CI] 1.06 - 21.16）和MBP波动（比值比1.26；95% CI 1.00 - 1.58）被确定为移植后1个月死亡率的独立预测因素，同时还有术前因素，包括严重肝性脑病和终末期肝病模型评分≥30分（曲线下面积0.82，P < 0.001）。
MBP波动和大量输血是LDLT后因ALF导致短期死亡率的术中预测因素。对术中表现给予更多关注应为ALF提供有价值的预后信息。
