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肝脏移植的供者选择

Author
Scott J Cotler, MD
Section Editor
Robert S Brown, Jr, MD, MPH
Deputy Editor
Anne C Travis, MD, MSc, FACG, AGAF
Translators
任祖海, 副主任医师，副教授

引言

供者器官短缺是肝脏移植的主要限制因素。最佳死亡供者一般是较为年轻、既往健康，因头部创伤、脑内出血或缺氧等原因发生致命性脑损伤的个体。由于供者器官的相对稀缺，移植中心已考虑使用边缘性供者的器官。

本专题将总结死亡供者的选择流程，并讨论与受者结局相关的供者特征。肝脏移植的患者选择、活体供肝肝移植、以及肝移植中的伦理问题将在别处讨论。 (参见“成人肝移植：患者选择和术前评估”和“活体肝移植”和“肝脏移植中的伦理问题”)

供者评估

脑死亡后捐献 — 美国器官共享联合网络(United Network for Organ Sharing, UNOS)提供了器官获取的最低标准指南。初始评估通常由当地的器官获取组织(organ procurement organization, OPO)进行。OPO工作人员会确认潜在供者符合脑死亡标准。由潜在供者血缘关系最近的亲属签署捐赠同意书。需检测ABO血型、身高、体重及胸围，因为受者匹配是以血型和供者器官大小为基础的。

要排除有捐献禁忌证的潜在供者。捐献禁忌证包括非肝脏的恶性肿瘤(不包括未行脑室腹腔分流术的原发性脑肿瘤)。在美国，抗HIV抗体血清阳性曾是捐献的绝对禁忌证。禁止这类捐献的部分原因是担心将HIV阳性器官移植到病情控制良好的HIV感染者体内，可能会导致耐药性HIV转移至受者体内。然而，由于HIV治疗已有改进且等候移植的HIV患者的死亡率较高，2013年美国通过了一条法令，废除了不能将感染HIV供者的器官移植给HIV阳性受者的禁令[1]。尽管通常认为败血症是一个捐献禁忌证，但已有菌血症供者的器官成功使用。例如，一项大型回顾性研究表明，对于接受菌血症和非菌血症供者器官的受者，30日移植物存活率和患者生存率均相近[2]。

OPO工作人员需采集病史，评估潜在供者有无物质滥用或酗酒史，并进行体格检查。实验室检查通常包括ABO血型、全血细胞计数(complete blood count, CBC)、生化检查、凝血酶原时间(prothrombin time, PT)、活化部分凝血活酶时间(partial thromboplastin time, PTT)、乙型肝炎病毒表面抗原(hepatitis B surface antigen, HBsAg)、抗乙型肝炎病毒核心抗原(hepatitis B core antigen, HBc)抗体(HBcAb)，抗丙型肝炎病毒(hepatitis C virus, HCV)抗体、抗HIV抗体、性病研究实验室试验(venereal disease research laboratory, VDRL)或快速血浆反应素(rapid plasma reagin, RPR)，以及抗巨细胞病毒(cytomegalovirus, CMV)抗体。若潜在供者住院时间曾超过72小时，则还要进行血培养和尿培养。许多OPO针对所有或特定的高风险供者进行HIV和HCV核酸检测(nucleic acid testing, NAT)，以缩短从感染发生到经ELISA检出感染之间的窗口期，从而降低病毒传播至受者的风险[3]。必要时还会进行超声成像检查或肝活检。

                    

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Literature review current through: 2017-06 . | This topic last updated: 2017-02-01.
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