蛋白酶抑制剂对原位肝移植术中促炎性细胞因子和氧自由基代谢的影响    作者;冯国辉，雷志礼，宇鹏，宁新宇，姜伟，王甜甜，李军摘要  目的  评价蛋白酶抑制剂乌司他丁（ulinary trypsin inhibitor，UTI）对原位肝移植术（orthotopic liver transplantation，OLT）中血浆促炎性细胞因子和氧自由基代谢水平的影响。方法  将20例择期行OLT手术患者随机分为两组。UTI组（U组，n=10）：切皮后将UTI 30万u加入100ml生理盐水，持续静脉输注1h，然后每4h重复1次。对照组（C组，n=10）：以等容量生理盐水代替。分别于麻醉后切皮前（T0）、无肝前期120min（T1）、无肝期30min（T2）、新肝期5min（T3）、新肝期60min（T4）和术毕（T5）抽取静脉血测定血浆IL-6、IL-8、TNF-和丙二醛（MDA）浓度，以及超氧化物歧化酶（SOD）活性。术中连续监测心输出量、混合静脉血氧饱和度、中心温度、ECG、CVP、PETCO2、SpO2、桡动脉压、肺动脉压。维持中心温度不低于35.5。结果  T0时组间血浆IL-6、IL-8、TNF-、MDA和SOD水平差异均无显著性（P0.05）。与T0比较，两组血浆IL-6、IL-8从T2T5各时间点均升高（P0.01）；两组血浆TNF-从T1T5各时间点均升高（P0.05或0.01）；两组血浆MDA从T3T5各时间点均升高（P0.05或0.01）；C组血浆SOD从T3T5各时间点降低（P0.01）；U组血浆SOD仅在T3时降低（P0.05）。与C组比较，U组血浆IL-6、IL-8水平在T2T5各时间点降低（P0.05或0.01），TNF-和MDA水平在T3T5各时间点降低（P0.05或0.01），SOD水平在T3T5各时间点升高（P0.05）。结论  UTI可抑制OLT导致的全身性炎性反应，减少自由基的产生。        关键词  蛋白酶抑制剂；肝移植；促炎性细胞因子；氧自由基        Effects of ulinastatin on proinflammatory cytokines and oxygen free radicals during orthotopic liver transplantation        FENG Guo-hui，LEI Zhi-li，YU Peng，et al.Department of Anesthesia，General Hospital of Chinese Peoples Armed Police Forces，Beijing 100039，China        Abstract  Objective  To evaluate the effects of ulinastatin on proinflammatory cytokines and oxygen free radical during orthotopic liver transplantation(OLT).Methods  Twenty ASA patients with end-stage liver diseases，undergoing OLT were randomly divided into two groups.Ulinastatin group received intravenous infusion of ulinastatin 3105IU in 100ml normal saline after skin incision and every 4 hours thereafter(n=10).Control group received same amount of normal saline instead of ulinastatin(n=10).Blood samples were taken before skin incision(T0)，120min after skin incision(T1)，30min after liver was removed(T2)，5min (T3) and 60min (T4) after reperfusion of the graft and at the end of operation (T5)for determination of plasma IL-6，IL-8，TNF-，MDA concentration and SOD activity.After anesthesia induced，cardiac output，mixed venous oxygen saturation and central venous temperature were continuously monitored during operation.ECG，CVP，SpO2，PETCO2，radial artery and MPAP were also continuously monitored during operation.PETCO2 was maintained at (3540)mmHg during operation.Blood temperature was maintained above 35.5 during operation.Results  Two group plasma IL-6 and IL-8 concentrations were significantly increased from T2 to T5 as compared with the baseline values(P0.05)，whereas plasma levels of TNF- were significantly increased from T1 to T5 and compared with in the group C pla1sma TNF-，IL-6 and IL-8 concentrations were significantly decreased.Two group plasma MDA did not change significantly before and during anhepatic phase but were significantly increased during reperfusion of the graft and at the end of surgery as compared with the baseline values(P0.01).Plasma MDA concentrations were significantly decreased in the group U compared with in the group C.SOD activity decreased from T3 to T5 in group C compared with the T0(P0.01).In group U SOD activity decreased at T3 compared with the T0(P0.05).but SOD activity in group U are higher than those in group C from T3 to T5 phase(P0.05).Conclusion  Ulinastatin inhibits release of proinflammatory cytokines and reduces production of oxygen free radicals during OLT.        Key words  ulinary trypsin inhibitor;liver transplantation;cytokines;oxygen free radicals        乌司他丁（ulinary trypsin inhibitor，UTI）是从男性尿中分离纯化的尿胰蛋白酶抑制剂，新近的研究发现它可以抑制体外循环引起的炎性因子释放1。目前UTI是否可以改善原位肝移植术（orthotopic liver transplantation，OLT）围术期炎性反应尚无定论。本研究拟观察UTI对OLT术中血浆促炎性细胞因子和氧自由基代谢的影响。1  资料与方法        1.1  一般资料  择期行OLT患者20例，ASA 或级。见表1        1.2  方法  随机分为两组，UTI组（U组，n=10）：切皮后将UTI（广东天普制药有限公司，批号02050104）30万IU加入100ml生理盐水，持续静脉输注1h，之后每隔4h重复使用；对照组（C组，n=10）：以等容量生理盐水代替。表1  两组患者一般资料比较  （xs）      两组麻醉诱导采用咪唑安定0.050.1mg/kg、依托咪酯0.3mg/kg、芬太尼5g/kg、维库溴铵0.1mg/kg静脉注射；吸入异氟醚，酌情追加芬太尼和维库溴铵维持麻醉和肌松。所有患者均行经典非转流术式，术中吸入纯氧，呼气末二氧化碳分压维持在3545mmHg（1kPa=7.5mmHg），麻醉诱导后经右侧颈内静脉或锁骨下静脉置入Swan-Ganz导管，使用Baxter Vigilance连续心输出量测定仪连续测定心输出量，混合静脉血氧饱和度及中心静脉血温，监测心电图、中心静脉压、脉搏血氧饱和度、桡动脉压、肺动脉压。将加温毯置于患者下肢及背侧，输液通路及加温输液装置相连，维持血温不低于35.5。        分别于麻醉后切皮前（T0）、无肝前期120min（T1）、无肝期30min（T2）、新肝期5min（T3）、60min（T4）和术毕（T5）抽取静脉血测定血浆IL-6、IL-8、TNF-（放射免疫分析法）和丙二醛（MDA）浓度（硫代巴比妥酸比色法），以及超氧化物歧化酶（SOD）活性（黄嘌呤氧化酶法），标准试剂盒由北京海科锐生物技术中心提供。        1.3  统计学方法  应用2004版CHISS软件进行统计学分析，计量资料以均数标准差（xs）表示，组间比较采用独立样本t检验，组内比较采用双因素方差分析，计数资料采用2检验，P0.05为差异有显著性。