Treatment of hepatic venocclusive disease with recombinant human tissue plasminogen activator and heparin in 42 marrow transplant patients
Treatment of hepatic venocclusive disease with recombinant human tissue plasminogen activator and heparin in 42 marrow transplant patients
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DOI：
10.1182/blood.v89.5.1501.1501_1501_1506
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发表时间：
1997-03-01
期刊：
影响因子：
20.3
通讯作者：
McDonald, GB
中科院分区：
文献类型：
--
作者：
Bearman, SI;Lee, JL;McDonald, GB
本报告的目的是审查弗雷德哈钦森癌症研究中心的经验，治疗患者的静脉闭塞性肝病（VOD）骨髓移植后使用重组人组织纤溶酶原激活剂（rh-tPA）和肝素。本文回顾了1991年2月至1995年12月间用rh-tPA和肝素治疗VOD的42例患者的病历。对rh-tPA和肝素的应答定义为开始治疗后10天内血清总胆红素降低50%。在rh-tPA和肝素治疗之前、之后和开始时，检查总血清胆红素、体重增加百分比和血清肌酐，以确定这些实验室值是否区分对治疗有反应的患者和无反应的患者。我们还评估了多器官衰竭的证据（需要补充氧气，需要血液透析，需要机械通气）或VOD致死性结局的计算概率是否可以区分应答者和非应答者。此外，出血作为溶栓治疗的主要并发症的发生率和结果进行了检查。12例患者对rh-tPA和肝素有反应，30例患者无反应。在治疗开始当天，治疗开始前、治疗开始后或治疗开始时的rh-tPA剂量、血清总胆红素和体重增加百分比，或在rh-tPA和肝素治疗开始当天计算的死于VOD的概率中，没有无应答者。在rh-tPA和肝素治疗开始前或开始时，需要透析或机械通气的无应答患者（11/30）多于应答患者（0/12），P= 0.0183。治疗开始时，无应答患者的血清肌酐（1.9+/-1.3 mg/dL）高于应答患者（1.1+/-0.4 mg/dL），P= 0.0794。10例患者发生重度出血事件，导致3例患者死亡，并可能导致另外3例患者死亡。使用rh-tPA和肝素治疗VOD在29%的患者中获得成功，但与危及生命的出血的显著风险相关。治疗开始前需要补充氧气、透析或机械通气是溶栓治疗无效的预后指标。我们不建议在已经发生多器官功能障碍的重度VOD患者中使用tPA和肝素治疗。(C)1997年，美国血液学会。
The purpose of this report is to review the Fred Hutchinson Cancer Research Center experience of treating patients with venocclusive disease of the liver (VOD) after marrow transplantation using recombinant human tissue plasminogen activator (rh-tPA) and heparin. The charts of 42 patients who had received rh-tPA and heparin for the treatment of VOD between February 1991 and December 1995 were reviewed. Response to rh-tPA and heparin was defined as a reduction in total serum bilirubin by 50% within 10 days of starting treatment. Total serum bilirubin, percent weight gain, and serum creatinine before, after, and at the start of rh-tPA and heparin were examined to determine whether these laboratory values distinguished patients who responded to treatment from those who did not. We also evaluated whether evidence of multiorgan failure (requirement for supplemental oxygen, requirement for hemodialysis, requirement for mechanical ventilation) or whether the calculated probability of a fatal outcome from VOD could discriminate responders from nonresponders. In addition, the incidence and outcome of bleeding as a major complication of thrombolytic therapy was examined. Twelve patients responded to rh-tPA and heparin and 30 patients did not. There were no nonresponders in the day treatment was started, dose of rh-tPA, total serum bilirubin, and percent weight gain before, after, or at the start of treatment, or the calculated probability of dying from VOD on the day treatment with rh-tPA and heparin was begun. More nonresponding patients required dialysis or mechanical ventilation (11 of 30) before or at the start of rh-tPA and heparin than responding patients (0 of 12), P=.0183. Serum creatinine was greater at the start of treatment in nonresponding patients (1.9+/-1.3 mg/dL) than in responding patients (1.1+/-0.4 mg/dL), P=.0794. Ten patients had severe bleeding episodes, which resulted in death in three patients and may have contributed to death in an additional three patients. Treatment for VOD using rh-tPA and heparin was successful in 29% of patients but was associated with a significant risk of life-threatening hemorrhage. Requirement for supplemental oxygen, dialysis, or mechanical ventilation before the start of treatment were prognostic indicators of no response to thrombolytic therapy. We do not recommend treatment using tPA and heparin in patients with severe VOD who have already developed multiorgan dysfunction. (C) 1997 by The American Society of Hematology.