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目的 评价血浆置换联合大剂量持续静脉-静脉血液透析滤过方法(CVVHDF)在慢加急性肝衰竭合并Ⅲ～Ⅳ期肝性脑病患者治疗中的疗效及评估其作为肝移植手术前准备措施的可行性. 方法 回顾性总结2015年3月至2017年9月内科重症监护室采用血浆置换联合CVVHDF模式大剂量持续血液净化治疗14例慢加急性肝衰竭伴有Ⅲ～Ⅳ期肝性脑病患者成功完成肝移植的临床资料.于治疗前后监测肝肾功能、凝血功能、动脉血pH、动脉血乳酸及血氨等指标,观察患者心率、血压、急性生理与慢性健康评分(APACHE) Ⅱ、神志恢复时间.两组间均数比较采用t检验.结果 14例患者治疗前后血清总胆红素(t=9.43,P＜0.01)、血清肌酐(t=3.40,P＜0.01)、血氨(t=10.64,P＜0.01)、凝血酶原活动度(t=9.19,P＜ 0.01)及血清乳酸(t=9.25,P＜0.01)等均有明显改善;心率(t=4.47,P＜ 0.01)、平均动脉压(t=4,41,P＜ 0.05)、呼吸频率(t=6.01,P＜ 0.01)、APACHEⅡ评分(t=7.19,P＜0.01)明显改善(P＜0.05).8例Ⅲ期肝性脑病患者经过间断血浆置换联合CVVHDF治疗3～ 14d后神志转清,6例Ⅳ期患者转成Ⅲ～Ⅱ期.14例患者均成功实施了肝移植手术.最短等肝时间为3d,最长为1个月.结论 血浆置换联合CVVHDF能够明显改善肝衰竭合并Ⅲ～Ⅳ期肝性脑病患者的肝肾功能,降低血氨水平,改善神志;有效地提高患者的平均动脉压,维持生命体征的稳定,保持水电解质及酸碱平衡,创造稳定的内环境,为肝移植的手术前准备提供有力的支持,为争取肝移植赢得时间.

Objective To evaluate the effect of plasma exchange combined with high-dose continuous venovenous hemodiafiltration method (CVVHDF) in the treatment of patients with acute-on-chronic liver failure with stage Ⅲ-Ⅳ hepatic encephalopathy and the feasibility ofpre-operative preparation for liver transplantation.Methods Clinical data of 14 cases of medical intensive care unit of our hospital with acute-on-chronic liver failure accompanied with stage Ⅲ-Ⅳ hepatic encephalopathy that underwent plasma exchange combined with high-dose CVVHDF from March 2015 to September 2017 were retrospectively summarized.The indexes of liver and kidney function,blood coagulation function,arterial blood PH,lactic acid and blood ammonia were monitored before and after treatment.Heart rate,blood pressure,APACHE Ⅱ score,and consciousness recovery time were observed.Student's t-test was used to compare the mean values between the two groups.Results Serum total bilirubin (t =9.43,P ＜ 0.01),serum creatinine (t=3.40,P ＜ 0.01),serum ammonia (t =10.64,P ＜ 0.01),prothrombin activity (t =9.19,P ＜ 0.01),serum lactate (t =9.25,P ＜ 0.01),heart rate (t =4.47,P ＜ 0.01),and mean arterial pressure (t =4,41,P ＜ 0.05) were significantly improved in 14 patients before and after treatment.In addition,respiratory rate (t =6.01,P ＜ 0.01) and APACHE Ⅱ score (t=7.19,P ＜ 0.01) were significantly improved (P ＜ 0.05).Eight patients with stage Ⅲ hepatic encephalopathy were treated with intermittent plasma exchange combined with CVVHDF for 3 to 14 days,and six patients with stage Ⅳ were transformed to stage Ⅲ to Ⅱ.Liver transplantation was successfully performed on 14 patients with shortest time duration of 3days,and longest time duration of 1 month.Conclusion Plasma exchange combined with CVVHDF can significantly improve liver and kidney functions,reduce blood ammonia level and improve mental health in patients with hepatic failure accompanied with stage Ⅲ-Ⅳ hepatic coma.In addition,it also effectively increases the average arterial pressure,maintain stability of vital signs,maintain fluids,electrolytes and acid-base balance,create a stable internal environment for liver transplantation before operation,and extend time for liver transplantation.