Xu Xuan, Yu Bang, Zhu Bin, Ren Haili, Feng Zhichun
Center of Children's Advanced Disease, Bayi Children's Hospital Affiliated to General Hospital of Beijing Military Command, Beijing 100700, China.
Center of Children's Advanced Disease, Bayi Children's Hospital Affiliated to General Hospital of Beijing Military Command, Beijing 100700, China. Email:
Zhonghua Er Ke Za Zhi. 2014 Jun;52(6):433-7.
To investigate the clinical application, indication, timing and prognosis of blood purification (artificial liver, BP) in treatment of acute liver failure in children.
Artificial liver was used to treat 30 cases of pediatric acute liver failure (PALF), who were hospitalized in pediatric intensive care unit of Bayi Children's Hospital Affiliated to Beijing Military Command General Hospital, during March 2010 to July 2013. Simple plasma exchange (PE) mode was used for PALF without complications, while PE combined with continuous veno-venous hemodiafiltration (CVVHDF) mode was used for PALF with cerebral edema and/or hepatorenal syndrome and/or serious abnormality of electrolyte and acid-base balance.
Sixteen cases survived and restored hepatic function, with a survival rate of 53.3%. Single PE therapy could significantly decrease total bilirubin (TBIL) from (293.96 ± 214.52) µmol/L to (155.64 ± 140.97) µmol/L (P = 0.033), increase prothrombin time activity (PTA) from (34.50 ± 18.34) % to (60.50 ± 33.97) % (P = 0.013), while it did not significantly influence ammonia from (156.43 ± 67.23) µmol/L to (124.03 ± 62.58) µmol/L (P = 0.156) and alanine transarninase (ALT) from (752.53 ± 1 291.84) U/L to (132.00 ± 98.57) U/L (P = 0.066). PE + CVVHDF therapy could significantly ameliorate TBIL from (326.90 ± 233.85) µmol/L to (157.53 ± 125.31) µmol/L (P = 0.033), ALT from (1 476.64 ± 1 728.18) U/L to (169.38 ± 207.18) U/L (P = 0.019), ammonia from (215.83 ± 83.92) µmol/L to (141.25 ± 63.09) µmol/L (P = 0.022) and PTA from (36.68 ± 23.13)% to (71.75 ± 50.50) % (P = 0.044). Prothrombin time (PT) from (29.71 ± 17.75)s to (16.27 ± 6.38)s (P = 0.008) , ALT from (1 574.11 ± 1 775.96) U/L to (145.81 ± 113.89 ) U/L (P = 0.003) , TBIL from (233.16 ± 219.70) µmol/L to (75.19 ± 86.07) µmol/L (P = 0.012) , ammonia from (182.75 ± 90.07) µmol/L to (101.81 ± 37.14) µmol/L (P = 0.002) and PTA from (38.38 ± 20.39)% to (83.13 ± 41.68)% (P = 0.001) in survived cases significantly ameliorated after BP therapy. TBIL from (394.04 ± 192.80) µmol/L to (249.34 ± 113.97) µmol/L (P = 0.023) in died cases declined significantly after BP therapy, while alteration of PT, ALT, ammonia , and PTA had no statistical significance (P > 0.10) after BP therapy.
PE + CVVHDF therapy could significantly ameliorate not only TBIL and PTA but also ammonia and ALT compared with single PE therapy. The decline of only an index like TBIL or ALT after BP therapy could not improve the prognosis. The inconsistency between serum bilirubin and ALT levels was an important factor that suggested poor prognosis of ALF, and it might increase survival rate to use BP therapy before that inconsistency emerged.
探讨血液净化（人工肝，BP）在小儿急性肝衰竭治疗中的临床应用、适应证、时机及预后。
采用人工肝治疗2010年3月至2013年7月在北京军区总医院附属八一儿童医院儿科重症监护病房住院的30例小儿急性肝衰竭（PALF）患儿。对于无并发症的PALF患儿采用单纯血浆置换（PE）模式，对于合并脑水肿和/或肝肾综合征和/或严重电解质及酸碱平衡紊乱的PALF患儿采用PE联合持续静脉-静脉血液透析滤过（CVVHDF）模式。
16例存活并恢复肝功能，存活率为53.3%。单纯PE治疗可使总胆红素（TBIL）从（293.96±214.52）μmol/L显著降至（155.64±140.97）μmol/L（P = 0.033），凝血酶原时间活动度（PTA）从（34.50±18.34）%升至（60.50±33.97）%（P = 0.013），而对氨从（156.43±67.23）μmol/L降至（124.03±62.58）μmol/L（P = 0.156）及丙氨酸转氨酶（ALT）从（752.53±1291.84）U/L降至（132.00±98.57）U/L（P = 0.066）无显著影响。PE + CVVHDF治疗可使TBIL从（326.90±233.85）μmol/L显著改善至（157.53±125.31）μmol/L（P = 0.033），ALT从（1476.64±1728.18）U/L降至（169.38±207.18）U/L（P = 0.019），氨从（215.83±83.92）μmol/L降至（141.25±63.09）μmol/L（P = 0.022），PTA从（36.68±23.13）%升至（71.75±50.50）%（P = 0.044）。存活病例经BP治疗后凝血酶原时间（PT）从（29.71±17.75）s改善至（16.27±6.38）s（P = 0.008），ALT从（1574.11±1775.96）U/L降至（145.81±113.89）U/L（P = 0.003），TBIL从（233.16±219.70）μmol/L降至（75.19±86.07）μmol/L（P = 0.012），氨从（182.75±90.07）μmol/L降至（101.81±37.14）μmol/L（P = 0.002），PTA从（38.38±20.39）%升至（83.13±41.68）%（P = 0.001）。死亡病例经BP治疗后TBIL从（394.04±192.80）μmol/L降至（249.34±113.97）μmol/L（P = 0.023），而BP治疗后PT、ALT、氨及PTA的变化无统计学意义（P＞0.10）。
与单纯PE治疗相比，PE + CVVHDF治疗不仅可显著改善TBIL和PTA，还可改善氨和ALT。BP治疗后仅TBIL或ALT等指标下降并不能改善预后。血清胆红素与ALT水平不一致是提示ALF预后不良的重要因素，在该不一致出现前采用BP治疗可能提高存活率。
