A Clinical And Experimental Study On The Protective Effects Of Ambroxol On Pulmonary Injury In Early Phase After Orthotopic Liver Transplantation

PartⅠClinical ObservationPartⅠ.ⅠThe incidence and related risk factors of early acute lung injury after orthotopic liver transplantationObjectives To analyze the incidence and related risk factors of acute lung dysfunction early after orthotopic liver transplantation. It will be facilitated to prevention and treatment of acute lung dysfunction after orthotopic liver transplantation.Materials and Methods Select cases from the patients having undergoing orthotopic liver transplantation without veno-venous bypass, aging from 15 to 65 years and having no chronic respiratory diseases and hyoxemia. The rejective criteria were as follow: (1) the patients dead or automatic discharging at the day after the OLT or during the OLT; (2) the patients suffered from severe surgical technic complications; (3) Initial poor graft function occurred; (4) marginal donor; (5) PAWP>18mmHg. 251 patients were enrolled in this analysis, who were divided into two groups according PaO2/FiO2≥300mmHg(group A) and <300 mmHg(group B). The analyzed factors related to pulmonary damage early after OLT were as follow: (1) the sex, age and weight of the recipients; (2) preoperative variables of recipients: Child and MELD score, the serum levels of creatinine, BUN, TB, albumin, prealbumin, fibrinogen and hemoglobin, WBC, BPC and INR; (3) the variables of donator: age, the time of warm and cold ischemia; (4) the intraoperative variables: operative time, anhepatic phase, the volumes of hemorrhage and blood-transfusion(red cell suspension and plasma), transfusion volume; (5) postoperative variables of recipients: the serum levels of creatinine, BUN, TB, albumin, ALT, sodium and potassium, fibrinogen and hemoglobin, WBC, BPC and INR.Results 1. The ALI and ARDS incidences early after OLT were 25.5%(65/251) and 4.8%(12/265) respectively. 2. Single factor analysis showed that the factors having significant difference between group A and group B were as follow;the age of the recipients, preoperative variables (Child and MELD score, the preoperative serum levels of BUN, TB, prealbumin, fibrinogen and hemoglobin, WBC, BPC and INR), the intraoperative variables(the volumes of hemorrhage and blood-transfusion including red cell suspension and plasma) and the postoperative variables(the serum levels of BUN, TB, sodium, fibrinogen and hemoglobin, WBC, BPC and INR). 3. The significant factors were put to the analysis of LOGISTIC regression, which showed that the age of recipients, preoperative Child score, BUN and INR, intraoperative hemorrhage volume, postoperative serum level of sodium were are the independent risks contributing to ALI.Conclusions The ALI incidence early after OLT was high but the ARDS incidence was low. The age of recipients, preoperative Child score, BUN and INR, intraoperative hemorrhage volume and postoperative serum level of sodium maybe the main risk factors to ALI early after OLT.PartⅠ.ⅡA Clinical Study on the Pulmonary Protective Effects of Ambroxol in Early Phase after Orthotopic Liver TransplantationObjectives Through investigate the influence of ambroxol with various dose on the incidences of ALI and pulmonary infection in early phase after orthotopic liver transplantation, evaluate the pulmonary protective effects of ambroxol and approach the optimal dose to the postoperation.Material and Methods Select cases from the patients having undergoing orthotopic liver transplantation without veno-venous bypass, aging from 15 to 65 years and PaO2/FiO2>300 right after OLT. The rejective criteria were as follow: (1) the patients dead or automatic discharging during the observation; (2) the patients suffered from severe surgical technic complications; (3) Initial poor graft function occurred; (4) PAWP>18mmHg; (5) the patients who couldn't maintain the group therapy. 187 patients were enrolled in this study, who were divided into 5 groups and given different day dose of ambroxol respectively: group A (25 persons) 90mg, group B(33 persons) 180mg, group C(50 persons)360mg, group D (44 persons)480mg, group E(35 persons). Investigate the incidences of ALI and pulmonary infection in each group in 5d after orthotopic liver transplantation.Results 1. There were inverse correlations between the daily dose of ambroxol and the incidences of ALI and pulmonary infection in 5d after orthotopic liver transplantation with correlation coefficients -2.020and -2.201 (P<0.05) respectively. Through Probit regression analysis by SPSS software, the estimated daily dose which cut down the incidence of ALI below 10% is 527mg and the one which cut down the incidence of pulmonary infection below 20% is 558mg.Conclusions The medium dosage of ambroxol could cut down the the incidences of ALI and pulmonary infection in early phase after orthotopic liver transplantation, and so it had the pulmonary particularly protective effects. For prevention of ALI and pulmonary infection in early phase after OLT the recommended daily dose of ambroxol maybe is above 480mg.PartⅡExperimental StudyPartⅡ.ⅠExperimental Study on Pulmonary Injury Early after Orthotopic Liver Transplantation in RatsObjective To investigate the character and mechanism of pulmonary injury early after orthotopic liver transplantation through establishing a model of OLT in rats and observing the changes of pulmonary tissues, function and molecular level.Methods Select adult male Sprague-Dawley rats, weighted from 200g to 250g. 54 rats were randomly allocated into 2 groups according to the ratio 1:8: Sham group(6) and OLT group(48). The 48 rats of OLT group were divided into 2 groups(donators and recipients) according to the weights, which weights of donators were slightly less than of recipients. 24 cases of rat OLT by random pair were performed by using two-cuffed technique with some modification. After OLT 24 model rats were divided randomly into 3h,6h,12h,24h group according different reperfusion time after the OLT. Sham group were killed for research 3h after the sham operation. The partial pressure of oxygen in arterial blood, lung tissue wet weight/dry weigh ratio(W/D), lung malondialde-hyde (MDA) content and myeloperoxidase (MPO) activities were measured at different time points after OLT. The changes in the expression of ICAM-1 and NF-κB protein were observed with immunocytochemistry at different time points after OLT. The histological appearances of the lungs were observed under histology and histological score of lung damage were analyzed on computer.Result Oxygenation index had a transient decrease in at 3h and 6h after OLT, and then work up. At 24h, the oxygenation index had no significant difference compared with Sham group. The W/D of lung was significantly higher in groups sacrificed at time points after OLT(P<0.05),highest at 3h, 6h and then descended. After OLT MDA content and MPO activity were significantly higher than those of Sham group (P<0.001). Among the OLT groups 24h group had a significant decrease compared with 3h group in MDA content and MPO activity. The positive index of expression of ICAM-1 were obviously up-regulated at 3h, 6h and 12h after OLT , highest at 3h and then descending, whereas had no significant difference between 24h group and Sham group, but there was no significant difference between 12h and 24h. The positive index of expression of NF-κB were obviously up-regulated at all time points after OLT, no significant difference between 12h and 24h, highest at 3h and then descending rapidly after 6h. Histological examination demonstrated the injuries of lung tissues after OLT. By optical microscopy, the structure of lung was disorder, the septum of alveolus became wider, part of the pulmonary alveolus was atrophic, inflammatory cells infiltrating was obvious at 3h and 6h. After 12h the structure of alveolus gradually recovered. Histological score of lung damage were obviously higher at 3h, 6h and 12h after OLT, highest at 3h and then descending, and at 24h had no significant difference compared with Sham group.Conclusion Although the decrease of pulmonary function is transient, we confirmed the acute pulmonary pathological damages early after OLT, which were obvious at 3h~6h and recovered gradually at 12~24h. The mechanism of the lung injury may be attributable to more generation of oxygen-derived free radidicals, activation of NF-κB, up-regulation of the expression of ICAM-1 and pulmonary PMN aggregation. Although the pulmonary tissue structure almost recovered,the local inflammatory reaction still existed in lung.PartⅡ.ⅡExperimental Study on Pulmonary Protective Effects of Ambroxol Early after Orthotopic Liver Transplantation in RatsObjective To investigate the pulmonary protective effects of ambroxol administrated ahead in various dosages early after orthotopic liver transplantation compared with postoperative administration and contrasted to ulinastatin. It will be facilitated to pulmonary protection and selection of the kind, dosage and administration of drug early after orthotopic liver transplantation.Methods Select 66 adult male Sprague-Dawley rats, weighted from 200g to 250g. randomly allocated into 2 groups according to the ratio 1:10: Sham group(6) and OLT group(60). The 60 rats of OLT group were divided into 2 groups(donators and recipients) according to the weights, which weights of donators were slightly less than of recipients. 30 cases of rat OLT by random pair were performed, divided randomly into 5 groups: group A (no administration), group M (large dosage of ambroxol administrated ahead), group N (medium dosage of ambroxol administrated ahead), group P ((large dosage of ambroxol administrated postoperatively) and group U (10~5U/kg dosage of ulinastatin administrated ahead). All groups of rats were killed 3h after operation. The partial pressure of oxygen in arterial blood, lung tissue wet weight/dry weigh ratio(W/D), lung malondialde-hyde (MDA) content and myeloperoxidase (MPO) activities were measured at different time points after OLT. The changes in the expression of ICAM-1 and NF-κBp65 protein by immunocytochemistry and SP-A protein by Western Blot were observed at different time points after OLT. The histological appearances of the lungs were observed under histology and histological score of lung damage were analyzed on computer.Result 1. Oxygenation index: Compared with the sham group, oxygenation index of all groups undergone OLT had a obvious decrease (P<0.05). Among the OLT groups, there no significant difference among groups M, N and U (P>0.05) and between groups U and P, while groups M and N better than group P (P<0.05). 2. W/D of lung: Compared with the sham group, W/D of all groups undergone OLT had a dramatically increase (P<0.001). All groups with drug intervention were alleviated compared with model group, group M alleviated most. 3. Pulmonary MDA content: Compared with the sham group, MDA of all groups undergone OLT had a marked increase (P<0.001). All groups with drug intervention were alleviated compared with model group, groups M and N better than groups P and U. 4. Pulmonary MPO activity: Compared with the sham group, MPO of all groups undergone OLT had a dramatically increase (P<0.001). All groups with drug intervention were alleviated compared with model group, group M alleviated most but having no significant difference compared with group N while group N no statistically better than groups P and U. 5. The positive index of expression of ICAM-1 in lung: Compared with the sham group, The positive index of all groups undergone OLT had a obvious increase (P<0.05). All groups with drug intervention were alleviated compared with model group, groups M and U better than groups N and P. 6. The positive index of expression of NF-κBp65 in lung: Compared with the sham group, The positive index of all groups except group M undergone OLT had a obvious increase (P<0.05). All groups with drug intervention were alleviated compared with model group(P<0.001), group M most , then group U and group N next. 7. The relative magnitude of expression of SP-A in lung: The relative magnitude of all groups except group M undergone OLT had a obvious decrease (P<0.001). All groups with drug intervention were improved compared with model group(P<0.001), group M most , then group N and P, group U in fine, but group P no statistically better than group U. 8. Histological score of lung damage: Compared with the sham group, The score of all groups undergone OLT had a obvious increase (P<0.05). All groups with drug intervention were alleviated compared with model group, group M better than group P.Conclusion Ambroxol has apparent pulmonary protective effects early after orthotopic liver transplantation, including lessening generation of oxygen-derived free radidicals, inhibiting activation of NF-κB and expression of ICAM-1, diminishing the aggregation of PMN in pulmonary capillary and interstitium and increasing synthesis of SP-A, which are dose-dependent. The effects of administration beforehand are better than postoperative administration and only need medium dosage. The effects of ambroxol are not inferior to that of ulinastatin and yet the price is much lower.