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背景:血浆置换既能机械性被动去除患者体内毒素,又能人为补充白蛋白、凝血因子等生物活性物质,部分替代正常肝脏功能,渐被临床用于各种原因所致的严重肝功能损害的替代治疗。目的:拟验证观察非生物型人工肝技术-血浆置换治疗慢性重型肝炎的疗效。设计、时间及地点:人工肝治疗前后临床症状演变和血液实验室指标变化的自身对照观察,于2001-03/2007-12在广西桂林市第三人民医院完成。对象:慢性重型肝炎患者121例,男105例,女16例,年龄25～50岁,全部为乙型肝炎患者,其中乙型戊型混合感染2例。方法:患者在恒温治疗室内,常规行血管穿刺插管建立体外循环通路。应用日本松和韶华公司Plasauto-IQ型全自动血浆净化装置及相应配套的管路、模型血浆分离器,按要求进行体外循环管路和血浆分离器的无菌生理盐水冲洗,再用肝素生理盐水预冲管路。每次置换前常规应用地塞米松5mg静推预防过敏反应。术中每次血浆置换量3000mL,血液泵流速60～100mL/min,术中常规补充葡萄糖酸钙,并酌情应用地塞米松、盐酸异丙嗪等抗过敏处理,术前、术中肝素负荷总用量为50～80mg,术后患者使用肝素封管。121例患者共进行183次治疗,平均每例1.5次,根据病情间隔2～4d进行1次,其中1次81例,2次28例,3次6例,4次3例,5次2例,6次1例。至首次血浆置换治疗开始算起,治疗后4周为疗程结束。主要观察指标:治疗前后及疗程结束时患者的临床症状、肝功能、由凝血酶原时间计算凝血酶原活动度及乙形肝炎病毒血清标志物,HBV-DNA改变情况。结果:慢性重型肝炎患者121例经183次血浆置换治疗后,临床症状出现不同程度改善,表现为食欲增加,体力增进,精神状态好转,腹胀减轻,血清总胆红素、直接胆红素、谷氨酸丙酮酸转氨酶、谷氨酸草酰乙酸转氨酶、清蛋白、球蛋白、肌酐等生化指标较治疗前明显下降,凝血酶原活动度明显升高。183例次治疗过程中,出现低血钙、血浆过敏、血压下降等反应共180例次,总发生率为98.3%。临床好转率为64.5%,其中早期83.8%,中期46.9%,晚期6.7%,同时1次与多次人工肝治疗临床好转率比较后者明显高于前者,两者比较差异显著。结论:人工肝治疗对早期慢性重型肝炎患者疗效好,多次人工肝治疗比1次治疗效果为佳。
Background: Plasma exchange can remove the toxins from the body of patients mechanically and passively, but also can supplement the bioactive substances such as albumin and coagulation factors, partially replacing the normal liver function, and gradually being used clinically in the treatment of severe liver damage caused by various causes Alternative treatment. OBJECTIVE: To verify the efficacy of non-bioartificial liver technique - plasma exchange in the treatment of chronic severe hepatitis. DESIGN, TIME AND SETTING: The self-controlled observation of clinical symptoms before and after artificial liver treatment and changes of blood laboratory indexes was performed at the Third People’s Hospital of Guilin, Guangxi from March 2001 to December 2007. Subjects: 121 patients with chronic severe hepatitis, 105 males and 16 females, aged 25 to 50 years old, all of whom were hepatitis B patients, including 2 cases of mixed infection of type B and E. Methods: The patients in the thermostatic treatment room, conventional vascular puncture intubation to establish extracorporeal circulation pathway. Application Songshe and Shaohua company Plasauto-IQ automatic plasma purification device and the corresponding supporting pipe, model plasma separator, on request, the extracorporeal circuit and plasma separator sterile saline irrigation, and then heparin saline Pre-punched pipe. Pre-replacement routine dexamethasone 5mg anti-allergic reactions. Intraoperative plasma exchange volume of 3000mL, blood pump flow rate of 60 ~ 100mL / min, intraoperative conventional calcium gluconate, and dexamethasone, promethazine hydrochloride and other anti-allergic treatment, preoperative and postoperative heparin load The dosage is 50 ~ 80mg, postoperative patients use heparin sealing tube. A total of 121 patients treated 183 times, an average of 1.5 cases per case, according to the disease interval of 2 ~ 4d for 1 time, including 81 cases, 28 cases of 2 times, 3 times in 6 cases, 4 times in 3 cases, 5 times in 2 cases , 6 times in 1 case. To the beginning of the first plasma exchange treatment, 4 weeks after treatment for the end of treatment. MAIN OUTCOME MEASURES: Clinical symptoms and liver function of patients before and after treatment and at the end of treatment. Prothrombin activity, hepatitis B virus serum markers and HBV-DNA changes were calculated from prothrombin time. Results: 121 patients with chronic severe hepatitis after 183 plasma exchange treatment, the clinical symptoms showed different degrees of improvement, manifested as increased appetite, physical strength, mental status improved, reduced abdominal distension, serum total bilirubin, direct bilirubin, Valley Glutamate oxaloacetate transaminase, albumin, globulin, creatinine and other biochemical indicators decreased significantly before treatment, prothrombin activity was significantly higher. 183 cases of treatment, there were 180 cases of hypocalcemia, plasma allergy, decreased blood pressure and other reactions, the total incidence was 98.3%. The clinical improvement rate was 64.5%, of which 83.8% in the early stage, 46.9% in the middle stage, and 6.7% in the late stage. The rate of clinical improvement in one time and multiple artificial liver treatments was significantly higher than the former, and the difference was significant. Conclusion: Artificial liver therapy has a good effect on patients with early-stage chronic severe hepatitis, and the results of artificial liver treatment more than once are better.