血液净化(人工肝)在急性肝功能衰竭患儿中的临床应用

Objective To investigate the clinical application,indication,timing and prognosis of blood purification (artificial liver,BP) in treatment of acute liver failure in children.Method Artificial liver was used to treat 30 cases of pediatric acute liver failure (PALF),who were hospitalized in pediatric intensive care unit of Bayi Children's Hospital Affiliated to Beijing Military Command General Hospital,during March 2010 to July 2013.Simple plasma exchange (PE) mode was used for PALF without complications,while PE combined with continuous veno-venous hemodiafiltration (CVVHDF) mode was used for PALF with cerebral edema and/or hepatorenal syndrome and/or serious abnormality of electrolyte and acid-base balance.Result Sixteen cases survived and restored hepatic function,with a survival rate of 53.3％.Single PE therapy could significantly decrease total bilirubin (TBIL) from (293.96 ± 214.52)μmol/L to (155.64 ± 140.97) μmol/L(P =0.033),increase prothrombin time activity (PTA) from(34.50 ± 18.34) ％ to (60.50 ± 33.97) ％ (P =0.013),while it did not significantly influence ammonia from (156.43 ± 67.23) μmol/L to(124.03 ± 62.58) μmol/L (P =0.156) and alanine transarninase (ALT)from (752.53± 1 291.84)U/L to(132.00 ± 98.57) U/L (P =0.066).PE + CVVHDF therapy could significantly ameliorate TBIL from(326.90 ± 233.85) μmol/L to (157.53 ± 125.31) μmo]/L(P =0.033),ALT from(1 476.64 ± 1 728.18) U/L to (169.38 ± 207.18) U/L (P =0.019),ammonia from (215.83 ± 83.92) μmol/L to (141.25 ± 63.09) μmol/L (P =0.022) and PTA from (36.68 ± 23.13) ％ to (71.75 ± 50.50)％ (P=0.044).Prothrombin time (PT) from (29.71 ±17.75)s to (16.27 ±6.38)s(P=0.008),ALT from (1 574.11 ± 1 775.96) U/L to (145.81 ± 113.89) U/L (P =0.003),TBIL from (233.16 ±219.70) μmol/L to (75.19 ±86.07) μmol/L(P =0.012),ammonia from (182.75 ± 90.07) μmol/L to (101.81 ± 37.14) μmol/L (P =0.002) and PTA from (38.38 ± 20.39) ％ to (83.13 ± 41.68) ％ (P =0.001) in survived cases significantly ameliorated after BP therapy.TBIL from (394.04 ± 192.80) μmol/L to (249.34 ± 113.97) μmol/L(P =0.023) in died cases declined significantly after BP therapy,while alteration of PT,ALT,ammonia,and PTA had no statistical significance (P ＞0.10) after BP therapy.Conclusion PE + CVVHDF therapy could significantly ameliorate not only TBIL and PTA but also ammonia and ALT compared with single PE therapy.The decline of only an index like TBIL or ALT after BP therapy could not improve the prognosis.The inconsistency between serum bilirubin and ALT levels was an important factor that suggested poor prognosis of ALF,and it might increase survival rate to use BP therapy before that inconsistency emerged.