目的

探讨脂肪变性供肝在成人劈离式肝移植（SLT）中应用的安全性和临床疗效。

方法

回顾性分析2014年7月至2022年1月在中山大学附属第三医院行SLT的67例供受体临床资料。供受者或（和）家属均签署知情同意书，符合医学伦理学规定。供者男56例，女11例，平均年龄（33±13）岁；DBD 60例，DCD 7例。67例受者中，男51例，女16例，平均年龄（51±12）岁；原发病包括乙型病毒性肝炎（乙肝）或丙型病毒性肝炎（丙肝）后肝硬化24例，肝恶性肿瘤20例，肝衰竭21例，遗传代谢性疾病2例；终末期肝病模型（MELD）评分中位数为25（8～40）分。供者和受者经过严格筛选和匹配，选择循环稳定的供者，尽可能缩短冷缺血时间≤8 h，供者血钠水平＜160 mmol/L，并优化供肝获取劈分流程。根据供肝脂肪变性分级，将接受相应供肝的受者分为S0组（脂肪变性程度＜10%）和S1组（脂肪变性程度介于10%～20%）。观察术后两组受者的移植肝功能恢复情况及围手术期并发症发生率和预后。术后 7 d 早期移植物功能障碍（EAD）发生率比较采用χ²检验；术后生存分析采用Kaplan-Meier法和Log-rank检验。

结果

S0组和S1组术后血管并发症发生率分别为6%（3/54）、0，胆道并发症发生率分别为7%（4/54）、8%（1/13），术后EAD发生率分别为13%（7/54）和23%（3/13），差异均无统计学意义（P＞0.05）。67例受者均接受随访，术后随访时间13～115个月，中位随访时间57个月，随访期间死亡6例，其中S0组4例，S1组2例。两组术后30 d内均无死亡患者。S0组肝移植受者术后1、3年生存率分别为98.1%、92.4%，S1组分别为92.3%、80.8%，差异无统计学意义（χ²=0.726，P=0.394）。

结论

脂肪变性程度＜10%的供肝可用于SLT；对于脂肪变性程度介于10%～20%的供肝，通过在体劈离、冷缺血时间控制、更高的移植物重量与受者体重比（GRWR）和严格的受者选择等措施，亦可谨慎安全地在成人受体中实施SLT。

Objective

To evaluate the safety and clinical efficacy of donor livers with steatosis in adult split liver transplantation （SLT）.

Methods

Clinical data of 67 donors and recipients who underwent SLT in the Third Affiliated Hospital of Sun Yat-sen University from July 2014 to January 2022 were retrospectively analyzed. The informed consents of all donors and recipients or （and） their families were obtained and the local ethical committee approval was received. 56 donors were male and 11 female，aged（33±13） years on average，and 60 donors were DBD and 7 cases were DCD. Among 67 recipients，51 cases were male and 16 female，with an average age of （51±12） years. Primary diseases included 24 cases of liver cirrhosis induced by viral hepatitis B （HBV） or viral hepatitis C （HCV），20 cases of malignant liver tumors，21 cases of liver failure and 2 cases of hereditary metabolic diseases，respectively. The median model for end-stage liver disease （MELD） score was 25（8-40）. After strict screening and matching of the donors and recipients，the donors with stable circulation were selected. The cold ischemia time （CIT） was shortened to ≤ 8 h. The serum sodium levels of the donors were maintained at ＜160 mmol/L. The process of donor liver splitting was optimized. According to the grading of donor liver steatosis，the recipients who were transplanted with corresponding donor livers were divided into the S0 group （degree of steatosis＜10%）and S1 group （degree of steatosis between 10% and 20%）. The recovery of liver allograft function，the incidence of perioperative complications and clinical prognosis were observed two groups. The incidence of early allograft dysfunction （EAD） at postoperative 7 d was compared with Chi-square test. Postoperative survival analysis was conducted by using Kaplan-Meier method and Log-rank test.

Results

In the S0 and S1 groups，the incidence of vascular complications was 6%（3/54） and 0，7%（4/54） and 8%（1/13）for biliary complications，and 13%（7/54） and 23%（3/13） for postoperative EAD，respectively，and no significant differences were observed between two groups （P＞0.05）. All 67 patients were followed up for 13-115 months，with a median follow-up time of 57 months. 6 patients died during postoperative follow-up，including 4 recipients in the S0 group and 2 in the S1 group. No patient died within postoperative 30 d in two groups. In the S0 group，the 1-year and 3-year survival rates of recipients were 98.1% and 92.4%，and 92.3% and 80.8% in the S1 group，with no statistical significance between two groups （χ²=0.726， P=0.394）.

Conclusions

Donor livers with a degree of steatosis of ＜10% can be used for SLT. For the donor livers with a degree of steatosis between 10% and 20%，SLT can be performed cautiously and safely in adult by means of liver splitting in vivo，CIT control，higher graft recipient weight ratio （GRWR） and strict recipient selection.