采用小容量血浆置换改善杀鼠剂诱导肝毒性患儿的无移植生存率
Improving Transplant-free Survival With Low-volume Plasma Exchange to Treat Children With Rodenticide Induced Hepatotoxicity.
作者信息
Thomas Leenath, Chandran Jolly, Goel Ashish, Jacob Ebor, Chacko Binila, Subramani Kandasamy, Agarwal Indira, Varughese Santosh, David Vinoi G, Daniel Dolly, Mammen Joy, Balakrishnan Vijayalekshmi, Balasubramanian Kunissery A, Lionel Arul P, Adhikari Debasis D, Abhilash Kundavaram P P, Elias Elwyn, Eapen Chundamannil E, Zachariah Uday
机构信息
Department of Hepatology, Christian Medical College, Vellore, India.
Department of Critical Care, Christian Medical College, Vellore, India.
出版信息
J Clin Exp Hepatol. 2023 Mar-Apr;13(2):252-258. doi: 10.1016/j.jceh.2022.10.013. Epub 2022 Nov 12.
BACKGROUND
In a prior report, no patient with rodenticidal hepatotoxicity who met Kochi criteria (MELD score ≥36 or baseline INR ≥6 with hepatic encephalopathy) (PMID: 26310868) for urgent liver transplantation survived with medical management alone. Plasma exchange (PLEX) may improve survival in these patients.
OBJECTIVES
We describe our experience with low-volume PLEX (PLEX-LV) in treating rodenticide ingestion induced hepatotoxicity in children.
METHODS
From prospectively collected database of rodenticidal hepatotoxicity patients managed as in-patient with department of Hepatology from December 2017 to August 2021, we retrospectively studied outcomes in children (≤18 years). Hepatotoxicity was categorized as acute liver injury (ALI, coagulopathy alone) or acute liver failure (ALF, coagulopathy and encephalopathy). Kochi criteria was used to assess need for urgent liver transplantation. The primary study outcome was one-month survival.
RESULTS
Of the 110 rodenticidal hepatotoxicity patients, 32 children (females: 56%; age: 16 [4.7-18] years; median, range) constituted the study patients. The study patients presented 4 (1-8) days after poison consumption (impulsive suicidal intent:31, accidental:1). Twenty children (62%) had ALI [MELD: 18 (8-36)] and 12 (38%) had ALF [MELD: 37 (24-45)].All children received standard medical care, including N-acetyl cysteine; ALF patients also received anti-cerebral edema measures. None of the patient families opted for liver transplantation. Seventeen children (ALI: 6, ALF: 11) were treated with PLEX-LV (3 [1-5] sessions, volume of plasma exchanged per session: 26 [13-38] ml/kg body weight) and peri-procedure low dose prednisolone.At 1 month, 28 of the 32 children (87.5%) were alive (4 ALF patients died). Of 10 children who met Kochi listing criteria for urgent liver transplantation, two children were ineligible for PLEX-LV (due to hemodynamic instability) and of the remaining 8 children treated by PLEX-LV, 6 (75%) survived.
CONCLUSIONS
PLEX-LV shows promise as an effective non-liver transplant treatment in children with rodenticidal hepatotoxicity.
背景
在之前的一份报告中，没有符合高知县标准（终末期肝病模型评分≥36或基线国际标准化比值≥6且伴有肝性脑病）（ PMID：26310868）进行紧急肝移植的杀鼠剂肝毒性患者仅通过药物治疗存活下来。血浆置换（PLEX）可能会提高这些患者的生存率。
目的
我们描述了我们在使用小容量PLEX（PLEX-LV）治疗儿童杀鼠剂摄入所致肝毒性方面的经验。
方法
从2017年12月至2021年8月肝病科前瞻性收集的杀鼠剂肝毒性住院患者数据库中，我们回顾性研究了儿童（≤18岁）的治疗结果。肝毒性分为急性肝损伤（ALI，仅凝血功能障碍）或急性肝衰竭（ALF，凝血功能障碍和脑病）。采用高知县标准评估紧急肝移植的需求。主要研究结局是1个月生存率。
结果
在110例杀鼠剂肝毒性患者中，32例儿童（女性：56%；年龄：16[4.7 - 18]岁；中位数，范围）构成研究对象。研究对象在摄入毒物后4（1 - 8）天就诊（冲动自杀意图：31例，意外：1例）。20例儿童（62%）患有ALI[终末期肝病模型评分：18（8 - 36）]，12例（38%）患有ALF[终末期肝病模型评分：37（24 - 45）]。所有儿童均接受了标准药物治疗，包括N - 乙酰半胱氨酸；ALF患者还接受了抗脑水肿措施。没有患者家属选择肝移植。17例儿童（ALI：6例，ALF：11例）接受了PLEX-LV治疗（3[1 - 5]次疗程，每次血浆置换量：26[13 - 38]ml/kg体重）以及围手术期低剂量泼尼松龙治疗。1个月时，32例儿童中有28例（87.5%）存活（4例ALF患者死亡）。在10例符合高知县紧急肝移植列入标准的儿童中，2例儿童因血流动力学不稳定不符合PLEX-LV治疗条件，其余接受PLEX-LV治疗的8例儿童中，6例（75%）存活。
结论
PLEX-LV显示出有望成为治疗儿童杀鼠剂肝毒性的一种有效的非肝移植治疗方法。
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