李氏人工肝系统治疗乙肝慢加急性肝衰竭的疗效和预后评价

发布时间：2018-04-07 16:10

本文选题：李氏人工肝　切入点：血浆置换滤过方法　出处：《浙江大学》2013年博士论文

【摘要】：乙肝病毒慢性感染过程中可能发生急性发作引起重型肝炎(慢加急性肝衰竭)、肝硬化、肝癌等情况,造成了巨大的社会负担和经济负担。乙肝肝衰竭病情危重,进展迅速,预后极差,目前内科综合治疗仍缺乏特效的治疗药物,病死率高达70%。李氏人工肝系统(Li's artificial liver system, Li-ALS)治疗重型肝炎肝衰竭获得重大突破,显著降低了患者病死率。早在2005年,李兰娟院士领导的人工肝团队就提出血浆置换联合血液滤过治疗中、晚期慢性乙型重型肝炎的疗效优于血浆置换的观点。本文进行了李氏人工肝系统血浆置换滤过方法治疗乙肝慢加急性肝衰竭35例的病例分析。本文以浙大一院人工肝中心2011.6.1到2012.1.30期间采用李氏人工肝系统血浆置换滤过方法治疗的乙肝慢加急性肝衰竭患者为研究对象,通过回顾性研究,分析了李氏人工肝系统治疗前后各种指标的变化,并建立了Cox比例风险回归模型,分析了影响慢加急性肝衰竭预后的因素。李氏人工肝系统血浆置换滤过方法治疗前后血三系都发生了显著的降低,并引起了治疗后血生化及凝血指标的极大改善。治疗后谷氨酸、甲硫氨酸、半胱氨酸、酪氨酸、组氨酸显著降低,其余氨基酸治疗后数值低于治疗前,但差异在统计学上不显著。1月和1年总体生存率分别为51.4%和40.0%。根据肝衰竭不同分期分层,早期1月和1年总体生存率分别为75.0%和50.0%；中期1月和1年总体生存率分别为63.2%和47.4%；晚期1月和1年总体生存率分别为25.0%和25.0%。用Cox比例风险回归模型进行回归分析,得到四个显著的变量：MELD评分(RR=1.379)、白细胞(RR=1.296).HBeAg(RR=0.083).胆碱酯酶/1000(RR=0.552)。血浆置换既可以除去血液中的中小分子物质和与血浆蛋白结合的大分子毒性物质,同时还可补充肝衰竭患者缺乏的凝血因子、白蛋白等。但其对水电解质平衡以及酸碱失衡等内环境紊乱的调节作用较小,对中小分子物质的清除能力不如血液滤过和透析,对水负荷过重的情况无改善作用,而血液滤过正好弥补了这些不足。晚期患者体内蓄积的毒素高于早、中期,李氏人工肝系统血浆置换滤过方法经过持续性的血液滤过,更大程度上清除了血液中的毒素从而进一步提高了晚期患者生存率。
[Abstract]:Severe hepatitis may occur in the process of chronic hepatitis B virus infection (chronic and acute liver failure, liver cirrhosis, liver cancer, and so on), resulting in a huge social and economic burden.Hepatitis B liver failure is in critical condition, rapid progress and poor prognosis. At present, comprehensive medical treatment is still lack of special treatment drugs, the mortality is as high as 70.Li-ALS artificial liver system (Li-ALS) has made a great breakthrough in the treatment of severe hepatitis liver failure, and has significantly reduced the mortality of patients.As early as 2005, the artificial liver team led by Academician Li Lanjuan proposed that the efficacy of plasma exchange combined with hemofiltration in the treatment of advanced chronic severe hepatitis B was better than that of plasma exchange.In this paper, 35 cases of chronic hepatitis B and acute hepatic failure were analyzed.The patients with chronic hepatitis B and acute liver failure treated by plasma exchange filtration in Li's artificial liver system between January 2011 and January 30, 2012 were selected as the study subjects, and a retrospective study was carried out on the patients with chronic hepatitis B and acute liver failure, who were treated with plasma exchange filtration method in Li's artificial liver system from January 1, 2011 to January 30, 2011.The changes of various indexes before and after the treatment of Li's artificial liver system were analyzed. The proportional risk regression model of Cox was established and the factors influencing the prognosis of chronic and acute liver failure were analyzed.The three blood lines of Li's artificial liver system were significantly decreased before and after treatment with plasma exchange filtration method, and the blood biochemical and coagulation indexes were greatly improved after treatment.After treatment, glutamate, methionine, cysteine, tyrosine, histidine were significantly decreased, the other amino acid values were lower than before treatment, but the difference was not statistically significant. The overall survival rates of 1 month and 1 year were 51.4% and 40.0%, respectively.According to different stages of liver failure, the overall survival rates of early 1 month and 1 year were 75.0% and 50.0%, those of middle stage and 1 year were 63.2% and 47.4%, and that of late January and 1 year were 25.0% and 25.0%, respectively.By using the Cox proportional risk regression model, four significant variables were obtained: rmeld 1.379, WBC RV 1.296, HBeAg-RN 0.083.Cholinesterase / RRN 0.552%.Plasma exchange can not only remove the small and medium molecular substances in blood and macromolecular toxic substances combined with plasma protein, but also supplement the coagulation factors, albumin and so on in the patients with liver failure.However, it has little effect on the balance of water and electrolyte and the disturbance of internal environment, such as acid and base imbalance. It has less ability to remove small and medium molecular substances than hemofiltration and dialysis, and has no effect on the situation of water overload.And hemofiltration makes up for these deficiencies.The accumulation of toxins in patients with advanced stage is higher than that in early and middle stage. Plasma exchange filtration method of Lee's artificial liver system through continuous hemofiltration to a greater extent clears the toxins in the blood and further improves the survival rate of patients with advanced stage.
【学位授予单位】：浙江大学
【学位级别】：博士
【学位授予年份】：2013
【分类号】：R512.62;R575.3

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