發(fā)布時(shí)間：2018-06-24 11:22

  本文選題：人工肝 + 急性肝衰竭��； 參考：《浙江大學(xué)》2015年博士論文

【摘要】：背景 肝衰竭是由多種因素引起肝細(xì)胞嚴(yán)重?fù)p害,導(dǎo)致其合成、解毒和生物轉(zhuǎn)化等功能發(fā)生嚴(yán)重障礙,出現(xiàn)以黃疸、凝血功能障礙、肝性腦病和腹水等為主要表現(xiàn)的一種臨床綜合征[1]。肝功能衰竭患者往往病情危重,進(jìn)展迅速,預(yù)后極差[2]。盡管隨著醫(yī)療技術(shù)的進(jìn)步,近年來(lái)在肝衰竭的診治上取得了較大的進(jìn)展,但其病死率仍然居高不下。根據(jù)病理組織學(xué)特征和病情的發(fā)展速度,肝衰竭通常分為急性肝衰竭、亞急性肝衰竭、慢加急性肝衰竭、慢性肝衰竭四類[3]。歐美國(guó)家,主要以藥物誘發(fā)的急性肝衰竭為主,其中乙酰氨基酚(acetaminophen)誘導(dǎo)的急性肝衰竭占50%左右,而在亞太地區(qū)則以病毒性肝炎(主要為乙型病毒)誘發(fā)的慢加急性肝衰竭最為常見(jiàn)[4]。肝移植是肝衰竭患者最有效的治療手段,但往往由于供體不足,即便在美國(guó),每年也僅有不足三分之一的病人能夠獲得肝移植的機(jī)會(huì),而更多患者在等待供體期間死去[5]。人工肝支持系統(tǒng)是一種有效的肝臟功能替代手段。它借助體外循環(huán)裝置,采用物理、化學(xué)、生物的血液凈化手段,可以暫時(shí)、部分替代肝臟功能,改善機(jī)體內(nèi)環(huán)境,促進(jìn)肝細(xì)胞再生[6],或者成為肝移植的“橋梁”,使患者能夠贏得更多的時(shí)間等待合適的供肝,降低圍手術(shù)期風(fēng)險(xiǎn),減少并發(fā)癥[7]。 目前,根據(jù)人工肝系統(tǒng)中是否包含活性細(xì)胞成分,人工肝支持系統(tǒng)可分為非生物人工肝及生物型人工肝兩大類。生物型人工肝是以人工培養(yǎng)具有活性的肝細(xì)胞為基礎(chǔ),與生物反應(yīng)器相結(jié)合,構(gòu)建的體外生物反應(yīng)裝置。目前在研究的生物人工肝系統(tǒng)主要有HepatAssist[8,9], ELAD[10-12], MELS[13,14], BLSS[15], AMC-BAL[16]等。生物人工肝支持系統(tǒng)是人工肝支持系統(tǒng)的主要研究方向,但現(xiàn)在技術(shù)發(fā)展仍不成熟,目前仍沒(méi)有一種治療系統(tǒng)被批準(zhǔn)用于臨床治療。非生物型人工肝是目前廣泛應(yīng)用于臨床的人工肝治療手段。國(guó)內(nèi)主要采用以血漿置換或者血漿置換聯(lián)合血液透析濾過(guò)、血漿灌流等治療方法為主,但往往因?yàn)檠獫{供應(yīng)緊張,大量的患者得不到及時(shí)有效的救治。在歐美則常采用基于白蛋白透析的多種血液凈化方法的聯(lián)合系統(tǒng),包括白蛋白透析吸附系統(tǒng)(包括單次白蛋白通過(guò)透析(single-pass albumin dialysis, SPAD)[17,18]、重復(fù)白蛋白透析(repeated albumin dialysis, RAD)、分子吸附再循環(huán)系統(tǒng)(molecular adsorbent recirculating system, MARS)[19-21]等。已有的研究表明該類方法缺乏補(bǔ)充蛋白質(zhì)、凝血因子等有益物質(zhì),難以完成肝臟合成功能的替代,且治療過(guò)程中消耗大量白蛋白,成本較高,療效難以令人滿意。如何高效整合各種基礎(chǔ)的血液凈化手段,構(gòu)建新的有效的組合式非生物型人工肝系統(tǒng),提高臨床治療的效果,目前是一個(gè)值得挑戰(zhàn)的課題。 最近,在李蘭娟院士指導(dǎo)下,圍繞著如何減少非生物人工肝治療過(guò)程中的血漿用量,最大效率的清除不同分子量的各類毒素,更好的實(shí)現(xiàn)肝臟功能的替代這些關(guān)鍵問(wèn)題,我們實(shí)驗(yàn)室團(tuán)隊(duì)結(jié)合了血漿置換聯(lián)合血漿吸附和血液濾過(guò)的優(yōu)勢(shì)探索出了一套名為李氏人工肝系統(tǒng)(Li's artificial liver system, Li-ALS)的方法,。該方法借鑒了MARS的多凈化循環(huán)設(shè)計(jì),構(gòu)建了一個(gè)多循環(huán)血液凈化系統(tǒng),通過(guò)多種凈化手段的聯(lián)合有效降低了血漿使用量,并且利用置換出的廢棄血漿作為血漿吸附濾過(guò)循環(huán)的循環(huán)介質(zhì),有效的解決了復(fù)雜凈化循環(huán)導(dǎo)致體外引血容量過(guò)大的問(wèn)題。 本研究中,我們利用D-氨基半乳糖建立豬肝衰竭模型,采用新型李氏人工肝系統(tǒng)對(duì)急性肝衰竭豬進(jìn)行治療,初步觀察其治療效果,評(píng)估該系統(tǒng)治療的有效性、穩(wěn)定性與安全性。 目的： 本研究構(gòu)建了一套新型李氏人工肝系統(tǒng),并采用豬急性肝衰竭模型,對(duì)新系統(tǒng)的安全性及有效性進(jìn)行評(píng)價(jià)。 方法： 選取體重18-23千克的雄性巴馬香豬40只作為模型動(dòng)物,頸靜脈置入6.5F雙腔靜脈導(dǎo)管,無(wú)麻醉?xiàng)l件下靜脈注射D-氨基半乳糖(1.3g/kg)誘導(dǎo)豬急性肝衰竭。D-gal注射36h后,實(shí)驗(yàn)用豬隨機(jī)抽簽法分為5組,每組8只,開始持續(xù)6小時(shí)的干預(yù)：(1)急性肝衰竭對(duì)照組(n=8)：動(dòng)物僅進(jìn)行6h麻醉和基本生命體征監(jiān)護(hù),不接受任何治療措施；(2)血漿循環(huán)吸附濾過(guò)治療組(n=8)：動(dòng)物先接受1h體外循環(huán),隨后進(jìn)行5h血漿循環(huán)吸附濾過(guò)治療；(3)低劑量血漿置換組(n=8)：動(dòng)物先接受1h血漿置換治療,血漿置換量按全血漿置換量的一半進(jìn)行,置換結(jié)束后再進(jìn)行5h體外循環(huán)；(4)李氏人工肝治療組(n=8)：動(dòng)物先接受1h低劑量血漿置換治療,隨后進(jìn)行5h血漿循環(huán)吸附濾過(guò)治療；(5)全血漿置換組(n=8)：動(dòng)物接受2h全血漿置換,置換結(jié)束后再進(jìn)行4h體外循環(huán)。觀察及檢測(cè)治療過(guò)程前后實(shí)驗(yàn)動(dòng)物臨床表現(xiàn)、動(dòng)物生存時(shí)問(wèn)、凝血功能、生化指標(biāo)、炎癥因子以及肝組織病理改變。 結(jié)果： 所有動(dòng)物均能很好的耐受6小時(shí)的麻醉及對(duì)應(yīng)的治療,5組實(shí)驗(yàn)動(dòng)物生存時(shí)間依次為60±2h.74±2h、75±2h、90±3h和88±3h。Kaplan-Meier生存分析提示,相較于急性肝衰竭對(duì)照組,所有治療組生存時(shí)間均顯著延長(zhǎng)(p0.001)；李氏人工肝治療組生存時(shí)間顯著長(zhǎng)于低劑量血漿置換及血漿循環(huán)吸附濾過(guò)組(p0.001),其生存時(shí)間略高于全血漿置換組,但差異不具有統(tǒng)計(jì)學(xué)意義(p0.05)。李氏人工肝治療之后,動(dòng)物的凝血功能得到顯著改善,凝血酶原時(shí)間顯著下降,纖維蛋白原水平顯著升高(p0.05),血清肝酶、膽紅素、膽汁酸、血氨水平顯著下降(p0.05),電解質(zhì)水平保持穩(wěn)定,炎癥因子上升趨勢(shì)得到明顯緩解,死后肝組織病理提示肝臟增生明顯,Ki-67標(biāo)志指數(shù)顯著較對(duì)照組顯著升高(p0.05)。 結(jié)論： 1.低劑量血漿置換和血漿循環(huán)吸附濾過(guò)治療均能顯著延長(zhǎng)急性肝衰竭小豬生存時(shí)間,兩者均為有效的方法； 2.李氏人工肝基于低劑量血漿置換并聯(lián)合血漿循環(huán)吸附濾過(guò),取得了較兩者單獨(dú)使用更加顯著的治療效果； 3.李氏人工肝僅用常規(guī)置換量一半的血漿,取得了與全量血漿置換相同的生存時(shí)間延長(zhǎng)效果,但治療過(guò)程中血漿用量顯著減少。
[Abstract]:background
Liver failure is caused by a variety of factors causing serious damage to the liver cells, resulting in serious obstacles to its synthesis, detoxification and biotransformation, and a clinical syndrome characterized by jaundice, coagulation dysfunction, hepatic encephalopathy and ascites, such as the main manifestation of [1]. liver failure, is often in critical condition, rapid progress and poor prognosis, although the prognosis is extremely poor [2]. although With the progress of medical technology, great progress has been made in the diagnosis and treatment of liver failure in recent years, but its mortality is still high. According to the histopathological characteristics and the development speed of the disease, the liver failure is usually divided into four kinds of [3]., European and American countries, including acute liver failure, subacute liver failure, chronic liver failure, chronic liver failure, and chronic liver failure. Acute liver failure induced by drugs, of which acetaminophen (acetaminophen) induced acute liver failure is about 50%, while in the Asia Pacific region, the most common [4]. liver transplantation is the most effective treatment for patients with chronic liver failure induced by viral hepatitis (mainly B virus), but often due to insufficient donor, Even in the United States, only less than 1/3 of the patients can get a liver transplant every year, and more patients who are waiting for the donor to die of the [5]. artificial liver support system are an effective alternative to liver function. To replace the liver function, improve the body environment, promote the regeneration of [6], or become a "bridge" of liver transplantation, so that patients can win more time to wait for the appropriate donor liver, reduce the risk of perioperative period, reduce the complications of [7].
At present, artificial liver support system can be divided into two major categories, namely, abiotic artificial liver and biotype artificial liver, based on the inclusion of active cell components in artificial liver system. Biological artificial liver is based on artificial liver cells with active liver and bioreactor combined with bioreactor. Artificial liver system mainly includes HepatAssist[8,9], ELAD[10-12], MELS[13,14], BLSS[15], AMC-BAL[16] and so on. Biological artificial liver support system is the main research direction of artificial liver support system, but the development of the technology is still not mature now, and there is still not a kind of treatment system approved for clinical treatment. The main use of artificial liver treatment in clinical. The main use of plasma exchange or plasma exchange combined hemodialysis filtration, plasma perfusion and other treatment methods, but often because of tension in the plasma, a large number of patients can not get timely and effective treatment. In Europe and America, often use a variety of blood purification methods based on albumin dialysis. The combined system, including the albumin dialysate adsorption system (including single-pass albumin dialysis, SPAD) [17,18], repeated albumin dialysis (repeated albumin dialysis, RAD), molecular adsorption recirculation system (molecular adsorbent recirculating), etc. The method is lack of supplemental protein, coagulation factor and other beneficial substances, it is difficult to complete the replacement of liver synthesis function, and the cost of a large amount of albumin is consumed in the treatment process, the cost is high and the curative effect is difficult to be satisfactory. How to efficiently integrate various basic blood purification methods and construct a new and effective combined non biological artificial liver system and improve the clinical treatment. The effect is a challenging task at the moment.
Recently, under the guidance of academician Li Lanjuan, we have combined the advantages of plasma exchange and plasma adsorption and hemofiltration on how to reduce the amount of plasma in the process of abiotic artificial liver treatment, to maximize the efficiency of eliminating the various molecular weights of all kinds of toxins, and to better realize the replacement of liver function. A set of methods called Li's artificial liver system (Li-ALS) was given. The method used the multi purification cycle design of MARS to construct a multi circulation blood purification system. The plasma use was effectively reduced by a combination of various purification methods, and the discarded plasma was used as a plasma adsorption. The circulating medium of filtration circulation can effectively solve the problem of excessive blood volume in vitro caused by complex purification cycle.
In this study, we used D- amino galactose to establish a pig liver failure model and use a new Li's artificial liver system to treat acute liver failure pigs. The effect of the treatment was preliminarily observed and the effectiveness, stability and safety of the system were evaluated.
Objective:
In this study, we constructed a new Li's artificial liver system and evaluated the safety and efficacy of the new system by using the pig acute liver failure model.
Method:
A 18-23 kilogram male Bama pig was selected as a model animal. The 6.5F double caval catheter was inserted into the jugular vein in the jugular vein. After the intravenous injection of D- amino galactogram (1.3g/kg) under the anesthesia to induce.D-gal injection of 36h in swine acute liver failure, the experiment was divided into 5 groups with 8 pigs in each group, which began for 6 hours of intervention: (1) acute liver. Exhaustion control group (n=8): animals were only subjected to 6h anesthesia and basic vital signs monitoring, and no treatment was accepted; (2) plasma circulatory adsorption filtration therapy group (n=8): animals received 1H extracorporeal circulation, followed by 5h plasma circulatory adsorption filtration therapy; (3) low dose plasma exchange group (n=8): the animals received 1H plasma replacement therapy first. 5h extracorporeal circulation was carried out at the end of total plasma replacement, and (4) Li's artificial liver treatment group (n=8): the animals were first treated with 1H low dose plasma exchange, followed by 5h plasma circulatory adsorption filtration, and (5) total plasma replacement group (n=8): animals received 2H total plasma replacement, and then reentered after the replacement. 4h cardiopulmonary bypass was performed. The clinical manifestations of experimental animals, animal survival time, coagulation function, biochemical indexes, inflammatory factors and pathological changes of liver tissue were observed and detected before and after the treatment.
Result:
All the animals were well tolerated for 6 hours of anesthesia and corresponding treatment. The survival time of the 5 experimental animals was 60 + 2h.74 + 2h, 75 + 2h, 90 + 3H and 88 + 3h.Kaplan-Meier. The survival time of all the treatment groups was significantly longer than that in the control group of acute liver failure (p0.001); the survival time of the Li's artificial liver treatment group was significant. The survival time was slightly higher than the total plasma exchange group (p0.001), but the difference was not statistically significant (P0.05). After Li's artificial liver treatment, the blood coagulation function of the animal was significantly improved, the prothrombin time decreased significantly, the fibrinogen level increased significantly (P0.05), the serum level was significantly higher (P0.05). The level of liver enzyme, bilirubin, bile acid and blood ammonia decreased significantly (P0.05), the level of electrolyte remained stable, and the rising trend of inflammatory factors was obviously alleviated. The liver histopathology indicated that liver hyperplasia was obvious, and the index of Ki-67 marker was significantly higher than that of the control group (P0.05).
Conclusion:
1. low dose plasmapheresis and plasma circulating adsorption filtration treatment can significantly prolong the survival time of pigs with acute liver failure, both of which are effective methods.
2. Li artificial liver based on low dose plasma exchange combined with plasma circulating adsorption filtration has achieved a more significant therapeutic effect than the two alone.
3. Li's artificial liver was used only half of the conventional replacement plasma, and the same survival time was achieved with the total amount of plasma exchange, but the amount of plasma was significantly reduced during the treatment.
【學(xué)位授予單位】：浙江大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2015
【分類號(hào)】：R318.14

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相關(guān)期刊論文 前1條

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本文編號(hào)：2061351