Emond J C, Aran P P, Whitington P F, Broelsch C E, Baker A L
Department of Medicine, University of Chicago Hospital, Illinois.
Gastroenterology. 1989 Jun;96(6):1583-8. doi: 10.1016/0016-5085(89)90530-1.
Liver transplantation is now performed for the treatment of fulminant hepatic failure, but the selection of patients for this procedure has been incompletely described. We used worsening hepatic encephalopathy, clinical evidence of brain edema, and prolongation of the prothrombin time after 24-48 h of intensive medical treatment as key factors influencing the decision to recommend liver transplantation. Thirty-seven patients (29 adult, 8 pediatric) were admitted with fulminant hepatic failure. Ten improved with medical treatment, so liver transplantation was not recommended. Twenty-seven deteriorated despite medical treatment. Eight of these, 7 with grade 4 hepatic encephalopathy and persistent coagulopathy, did not receive transplantation because of contraindications (n = 5), failure to find a donor (n = 1), or refusal of therapy (n = 2). None of these survived. Sixteen of the other 19 patients developed grade 4 hepatic encephalopathy, 5 had brain edema, and all had persistent coagulopathy, so liver transplantation was performed. One year actuarial survival was 58%. This retrospective analysis confirms that survival exceeding 50% can be obtained with liver transplantation in patients with fulminant hepatic failure. Additional studies of prognostic markers are needed to define the role of liver transplantation in the management of this disease.
目前肝移植用于治疗暴发性肝衰竭，但该手术患者的选择标准尚未完全明确。我们将严重肝性脑病恶化、脑水肿的临床证据以及强化内科治疗24 - 48小时后凝血酶原时间延长作为影响推荐肝移植决策的关键因素。37例（29例成人，8例儿童）暴发性肝衰竭患者入院。10例经内科治疗好转，因此不推荐肝移植。27例尽管接受内科治疗仍病情恶化。其中8例，7例有4级肝性脑病且存在持续性凝血功能障碍，因禁忌证（n = 5）、未找到供体（n = 1）或拒绝治疗（n = 2）未接受移植。这些患者均无存活。另外19例患者中的16例出现4级肝性脑病，5例有脑水肿，且均有持续性凝血功能障碍，因此进行了肝移植。1年实际生存率为58%。这项回顾性分析证实，暴发性肝衰竭患者接受肝移植可获得超过50%的生存率。需要进一步研究预后标志物以明确肝移植在该疾病治疗中的作用。
