吲哚菁绿试验对HBV相关肝脏疾病的肝脏储备功能及预后评估价值

目的通过吲哚菁绿清除试验评估HBV相关肝病患者肝脏储备功能,比较吲哚菁绿试验15分钟滞留率(indocyanine green retention rate at 15 minutes,ICG R15)与Child-Turcotte-Pugh score(CTP)分级和终末期肝病模型评分(the model for end-stage liver disease,MELD)对乙型肝炎肝硬化患者预后的评估能力。方法选取56例慢性乙型肝炎(chronic hepatitis B,CHB)和144例乙型肝炎肝硬化患者进行ICG R15检测,采用t检验比较CHB与乙型肝炎肝硬化两者ICG R15的差别,用Spearman相关性分析乙型肝炎肝硬化患者ICG R15与MELD评分及CTP分级的关系;通过受试者工作特征(ROC)曲线法分析ICG R15与MELD评分对肝硬化预后的评估能力。结果56例CHB患者ICG R15为1.40~9.50,平均值为4.43±2.19;144例乙型肝炎肝硬化患者ICG R15为2.40~60.00,平均值为22.80±16.00,显著高于CHB组,差异有统计学意义(P0.01)。CTP分级:A级患者70例,MELD评分4.99±2.76;B级患者54例,MELD评分6.24±4.69;C级患者20例,MELD评分11.71±3.77。在评价肝功能方面ICG R15与MELD评分及CTP分级呈正相关(r=0.414、r=0.67,P0.01)。ICG R15评估乙型肝炎肝硬化患者预后的曲线下面积(AUC)为0.903,最佳截点为9.55%,敏感度为71.5%,特异度为100%。MELD评分AUC为0.634,最佳截点为7.00,敏感度为36.8%,特异度89.3%。结论吲哚菁绿试验能动态反映肝脏储备功能,与MELD评分结合能更好地反映肝脏功能及评估患者预后。     

终末期肝病模型评价老年肝衰竭的预后相关性研究

目的:探讨老年肝衰竭患者和中青年肝衰竭患者的最佳MELD(终末期肝病评分模型)临界值与临床意义。方法:比较44例老年肝衰竭患者和107例中青年肝衰竭患者的TBil、Alb、Na~+、Cr、PT、PTA、INR、MELD评分与最佳临界值、R0C曲线下面积(AUC)及治疗3个月后死亡率。结果:老年肝衰竭和中青年肝衰竭在TBil、PT、PTA、INR、Na+及MELD分值比较差异无显著性意义(P0.05),但老年组肌酐(Cr)为(78.23±37.53)mmol/L,中青年组为(63.41±41.39)mmol/L,老年组明显高于中青年组(P0.05),老年组白蛋白(Alb)为(28.36±4.37)g/L,中青年组为(30.08±4.60)g/L,老年组明显低于中青年组(P0.05),老年组AUC为0.755,中青年组AUC为0.771,MELD对两组患者3个月后的预后预测有中等价值,老年组最佳临界值为24.5,中青年组最佳临界值为26.5,两组的准确率分别为74.0%和73.0%,Youden指数分别为0.549和0.481。结论:MELD能准确地预测老年肝衰竭患者3个月后的预后,老年肝衰竭患者的预后较中青年组要差。     

吲哚菁绿15分钟滞留率对HBV相关慢加急性肝衰竭患者病情及预后的评估价值

目的分析吲哚菁绿15 min滞留率(ICG R15)对慢加急性肝衰竭(ACLF)病情及临床预后的评估价值,为ACLF患者的病情评估及预后评价提供参考指标。方法以中国医科大学附属盛京医院2013年8月-2016年1月收治的127例ACLF患者为研究对象,按照临床分期分为早期组、中期组、晚期组,比较不同临床分期患者ICG R15、MELD评分及PT的差异,并按照患者90 d预后分为存活组、死亡组,比较两组患者上述指标间差异,总结ICG R15评价患者病情及预后的临床价值。计量资料组间比较采用独立样本t检验或单因素方差分析,采用LSD-t检验进行两两比较;计数资料组间比较采用χ2检验。结果不同临床分期组间ICG R15、PT、MELD评分差异均有统计学意义(F值分别为7.036、3.217、5.883,P值均0.05),其中中期组、晚期组ICG R15、PT、MELD评分[(53.96±10.01)%、(26.87±6.84)s、(31.56±4.17)分,(54.23±9.21)%、(28.43±3.61)s、(32.87±3.28)分]均高于早期组[(44.00±9.21)%、(19.79±2.82)s、(24.00±3.85)分],差异均有统计学意义(P值均0.05)。死亡组ICG R15、PT、MELD评分[(53.91±5.83)%、(29.85±3.52)s、(33.81±4.67)分]均高于存活组[(45.03±4.33)%、(21.35±3.18)s、(25.30±4.02)分],差异均有统计学意义(t值分别为9.85、14.20、10.99,P值均0.05)。以ICG R15=52%、PT=29 s、MELD评分=32分为截断值,不同指标水平患者病死率比较(22.39%vs 63.33%,25.71%vs 61.40%,21.54%vs 62.90%),差异均有统计学意义(χ2值分别为8.831、6.263、7.583,P值均0.05)。结论随着ACLF患者病情的加重与预后质量的下降,其PT、MELD评分逐渐升高,且ICG R15亦有所上升,根据上述指标变化能够早期全面评估患者病情及临床预后。     

吲哚菁绿清除试验联合甲胎蛋白对HBV相关慢加急性肝衰竭患者短期预后的评价

目的探讨吲哚菁绿清除试验(ICG)联合AFP对HBV相关性加急性肝衰竭(ACLF)短期预后的评估。方法回顾性分析55例HBV相关性ACLF患者的临床资料,检测患者确诊为肝衰竭24 h内吲哚菁绿15分钟滞留率(ICGR15),同时记录24 h内各项检查指标,并计算MELD评分。采用Spearman等级相关分析ICGR15和AFP与血TBil、INR、白蛋白、ALT、肌酐的相关性。对肝衰竭组患者进行3个月随访,确定存活及死亡情况,并对ICG R15、AFP进行分析。结果 55例肝衰竭患者死亡25例。生存组与死亡组患者的年龄、TBil、AFP、ICGR15、肌酐、INR等比较差异有统计学意义(P0.05)。血清ICGR15与TBil和MELD评分呈正相关(r值分别为0.279、0.766,P均0.05),与血AFP呈负相关(r=-0.311,P0.05);血清AFP与TBil呈负相关(r=-0.365,P0.05)。肝衰竭患者ICGR15≤50%组共17例,死亡3例;50%38例,死亡22例,2组比较,差异有统计学意义(χ2=7.674,P=0.006)。肝功能衰竭患者AFP≤10组共13例,死亡10例;AFP10组42例,死亡15例,2组比较,差异有统计学意义(χ2=6.799,P=0.009)。结论 ICGR15联合AFP能够较准确地预测HBV相关性ACLF的短期预后,肝衰竭患者ICGR1550%、AFP10时预后较差。     

吲哚菁绿清除试验对乙型肝炎肝硬化患者肝脏储备功能的评估价值

目的通过吲哚菁绿(ICG)清除试验评估乙型肝炎肝硬化患者肝脏储备功能,探讨ICG清除试验与Child-TurcottePugh(CTP)分级和MELD评分评价肝功能之间的关系。方法收集福建医科大学附属第一医院2012年1月-2015年1月住院的乙型肝炎肝硬化患者127例,进行ICG清除试验,计算患者的ICG血浆清除率值(K值)、有效肝血流量(EHBF)、ICG 15 min滞留率(ICG R15),以及CTP分级和MELD评分。组间比较采用方差分析,进一步两两比较采用LSD-t检验;相关性比较采用Spearman等级相关性分析;采用受试者工作特征曲线下面积(AUC)比较肝脏储备功能。结果乙型肝炎肝硬化患者CTP分级:A级患者63例,B级患者45例,C级患者19例。随着CTP分级升高,ICG R15逐渐增高,而EHBF和K值则逐渐降低,差异均有统计学意义(F值分别为146.96、91.26、40.94,P值均分别为0.001、0.003、0.005)。在评价肝功能方面ICG R15与MELD评分及CTP分级呈正相关(r值分别为0.525、0.838,P值均0.01),与EHBF及K值呈负相关(r值分别为-0.703、-0.901,P值均0.01)。ICG R15AUC为0.85,MELD评分AUC为0.65。结论 ICG消除试验能够准确动态反应肝脏储备功能,ICG R15评估肝脏储备功能优于CTP分级及MELD评分。     

Child-Pugh、MELD、MELD-Na和iMELD评分对乙型肝炎肝硬化患者3个月和1年生存率的评估价值

背景:肝硬化患者预后的评估系统主要包括Child-Pugh、终末期肝病评估模型(MELD)及其衍生评估系统等,为患者预后的评估提供了重要的指导价值,但其价值仍需更多的临床实践来证实。目的:探讨Child-Pugh、MELD、MELD-Na和i MELD评分对乙型肝炎肝硬化患者3个月和1年生存率的评估价值。方法:选取2012年1月—2016年12月西宁富康医院的乙型肝炎肝硬化患者236例,评估3个月和1年的生存率,计算各组Child-Pugh、MELD、MELD-Na和i MELD评分,以ROC曲线下面积(AUC)评估各评分预测乙型肝炎肝硬化患者3个月和1年生存率的准确性。结果:在236例乙型肝炎肝硬化患者中,随访3个月时死亡43例,随访1年时死亡71例,死亡原因为上消化道出血、肝性脑病、肝肾综合征、自发性腹膜炎和感染。3个月和1年生存组的Child-Pugh、MELD、MELD-Na和i MELD评分均显著低于相应死亡组(P0.05或0.01)。Child-Pugh、MELD、MELD-Na和i MELD评分预测乙型肝炎肝硬化患者3个月预后的AUC分别为0.791、0.818、0.853和0.897,四组相比差异有统计学意义(P0.05)。Child-Pugh、MELD、MELD-Na和i MELD评分预测乙型肝炎肝硬化患者1年预后的AUC分别为0.772、0.832、0.861和0.906,四组相比差异有统计学意义(P0.05)。Child-Pugh、MELD、MELD-Na和i MELD评分判断乙型肝炎肝硬化患者3个月和1年预后的准确性分别为70.1%、79.8%、86.2%和89.3%。结论:Child-Pugh、MELD、MELD-Na和i MELD评分对乙型肝炎肝硬化患者3个月和1年生存率的评估准确性较高,值得临床推广应用。     

乙型肝炎肝硬化患者的吲哚箐绿清除试验与Child-Pugh分级相关性的研究

目的对吲哚箐绿(ICG)清除试验与Child-Pugh评分进行对比研究,评估临床应用价值,探讨两者的相关性。方法选择2016年1月至2017年4月在青海省第四人民医院肝病科住院的101例患者,其中慢性乙型肝炎(CHB)41例,乙型肝炎肝硬化60例(Child-Pugh A级27例,Child-Pugh B级33例)。比较各组的ICG清除试验指标[ICG血浆清除率值(K值)、有效肝血流量(EHBF)、ICG 15 min滞留率(ICG R15)]、Child-Pugh分级、肝脏血清生物化学指标[总胆红素(TBil)、白蛋白(Alb)、凝血酶原时间(PT)],并分析ICG清除试验与Child-Pugh分级的相关性。结果 CHB组的ICG R15、K值、PT、Alb与肝硬化组比较,差异均有统计学意义(P均0.05);两组的EHBF、TBil比较,差异无统计学意义;肝硬化组中,Child-Pugh A级组与Child-Pugh B级组比较显示,随着Child-Pugh分级升高,ICG R15、PT、TBil水平升高,而K值、EHBF、Alb水平下降,差异均有统计学意义(P均0.05);ICG R15的受试者工作特征(ROC)曲线下面积(AUC)为0.827,截断值为13.3%时,敏感度为71%,特异度为85.2%;PT的AUC为0.886,截断值为14.4 s时,敏感度为71%,特异度为88.9%。结论 ICG清除试验与Child-Pugh评分和肝脏生物化学指标存在相关性,ICG R15与PT联合应用可能可以更好地评估肝功能储备。     

恩替卡韦治疗46例HBV相关慢加急性肝衰竭临床分析

目的探讨影响HBV-ACLF病情转归的危险因素及恩替卡韦治疗HBV-ACLF的效果。方法在基础治疗前提下加用恩替卡韦治疗46例HBV-ACLF患者,观察并比较患者生物化学指标、HBV DNA载量、并发症、MELD评分、有无肝硬化基础及患者1、3、6、12和24个月内生存情况,分析影响患者病情转归的危险因素。结果治疗1个月患者病死率为15.2%,PTA是影响转归的危险因素,生存组PTA为34.4±4.7,死亡组PTA为24.2±10.9,差异有统计学意义(P=0.049);治疗3个月患者病死率增加为21.7%,PTA和MELD评分是影响转归的危险因素。生存组PTA为35.0±4.2,死亡组PTA为25.1±9.2,差异有统计学意义(P=0.008);生存组MELD评分为22.2±3.5,死亡组MELD评分为29.1±7.7,差异有统计学意义(P=0.021);治疗6个月至24个月患者病死率增加为28.3%;MELD评分是影响转归的危险因素,生存组MELD评分为22.2±3.6,死亡组MELD评分为27.7±7.2,两组差异有统计学意义(P=0.019)。结论在基础治疗前提下加用恩替卡韦治疗HBV-ACLF,治疗3个月内患者病情转归的判断主要依赖PTA的结果;而治疗3个月后MELD评分对病情转归的判断更为可靠。     

血浆透析滤过治疗HBV相关慢加急性肝衰竭预后的影响因素分析

目的 探讨血浆透析滤过治疗HBV相关慢加急性肝衰竭(ACLF)的疗效及预后的影响因素。方法 回顾性分析41例接受血浆透析滤过治疗的HBV相关ACLF患者的临床资料,根据患者的短期预后(随访3个月)分为存活组和死亡组,分析两组间的临床指标和实验室检查结果,采用卡方检验、t检验分析血浆透析滤过的疗效及影响预后的相关因素。结果 41例患者血浆透析滤过治疗前的PTA为(18.33±7.75)%、TBil为(445.66±209.67)μmol/L、MELD评分为(32.08±6.75)分,3次血浆透析滤过治疗后第3天,PTA为(29.20±15.07)%、TBil为(396.88±151.78)μmol/L、MELD评分为(29.67±7.70)分,治疗前后比较,差异有统计学意义(t值分别为-3.826、2.042、2.026,均P0.05)。存活组12例,死亡组29例。存活组患者入院时合并肝硬化比例为16.7%,低于死亡组的68.9%(χ~2=7.351,P0.05);存活组诊断为肝衰竭至行血浆透析滤过治疗的间隔时间为(2.58±0.67)d,明显短于死亡组的(6.07±4.38)d(t=-4.167,P0.05);入院时存活组合并肝性脑病比例为83.3%,死亡组比例为96.6%,差异无统计学意义(χ~2=0.672,P0.05);存活组急性肾损伤(AKI)II期及III期患者比例为8.3%,而死亡组为65.5%,差异有统计学意义(χ~2=8.711,P0.05)。存活组患者3次血浆透析滤过治疗后第3天与治疗前相比,MELD评分下降(8.33±4.19)分、PTA增加(21.72±15.62)%,而死亡组患者与治疗前相比,MELD评分增加(0.55±6.66)分、PTA增加(6.38±17.47)%,两组比较,差异有统计学意义(t值分别为4.267、-2.633,均P0.05)。结论 血浆透析滤过治疗能改善HBV相关ACLF中晚期患者的肝功能及凝血功能;治疗前具有肝硬化基础、肝衰竭病程长、AKI分期高的患者预后差;治疗72 h后,PTA、MELD评分有显著改善的患者预后佳。     

应用MELD-Na模型评估失代偿期肝硬化患者的短期预后

目的评估终末期肝病血清钠(MELD-Na)、终末期肝病模型(MELD)及Child-Pugh评分系统对失代偿期肝硬化患者短期预后的预测价值。方法对具有完整记录和随访结果的96例失代偿期肝硬化患者的资料进行分析,分别计算每例患者的Chlid-Pugh、MELD及MELD-Na分值,使用受试者工作曲线(ROC)及曲线下面积(AUC)比较3种评分系统判断失代偿期肝硬化患者生存3个月的准确性。结果 96例患者3个月内有25例患者死亡。死亡组的Child-Pugh、MELD及MELD-Na评分均高于生存组(P0.01);MELD-Na和MELD评分在判断患者3个月生存时间的ROC曲线AUC均大于Child-Pugh(P0.001,P0.01),MELD-Na和MELD评分AUC差异均无统计学意义(P0.05)。结论 MELD-Na是判断失代偿期肝硬化患者短期预后的一个较好指标,其准确性优于Child-Pugh分级,但与MELD评分相比无明显差异。     

吲哚菁绿清除试验和终末期肝病模型评分

目的探讨吲哚菁绿(ICG)清除试验与4种终末期肝病模型评分(MELD、MELD-Na、MESO、iMELD)之间的关系。方法 70例失代偿期肝硬化患者行ICG清除试验检测15分钟滞留率(R15)和血浆清除率(K);同时计算患者MELD、MELD-Na、MESO和iMELD评分,采用Spearman等级相关性分级及LSD检验,比较ICGR15、K值与MELD、MELD-Na、MESO和iMELD评分之间的关系。结果随着Child-Pugh分级的升高,R15、MELD、MELD-Na、MESO、iMELD评分升高,K值降低。R15与MELD、MELD-Na、MESO、iMELD呈正相关(r=0.59、0.56、0.61、0.63,P<0.05),K值与MELD、MELD-Na、MESO、iMELD评分呈负相关(r=-0.55、-0.53、-0.58、-0.59,均P<0.05)。结论 R15和K值与MELD、MELD-Na、MESO、iMELD评分关系密切;R15与4种终末期肝病模型评分相关性比K值显著,其中R15与iMELD相关性更加显著。     

Evaluation of effect of hybrid bioartificial liver using end-stage liver disease model

AIM: To study the role of hybrid bioartificial liver (HBL) in clearing proinflammatory cytokines and endotoxin in patients with acute and sub-acute liver failure and the effects of HBL on systemic inflammatory syndrome (SIRS) and multiple organ dysfunction syndrome (MODS).METHODS: Five cases with severe liver failure (3 acute and 2 subacute) were treated with HBL. The clinical signs and symptoms, total bilirubin (TBIL), serum ammonia,endotoxin TNF-~, 1L-6 and prothrombin activity (PTA),cholinesterase (CHE) were recorded before, during and after treatment. The end-stage liver disease (MELD) was used for the study.RESULTS: Two patients were bridged for spontaneous recovery and 1 patient was bridged for OLT successfully.Another 2 patients died on d 8 and d 21. The spontaneous recovery rate was 30.0%. PTA and CHE in all patients were significantly increased (P&lt;0.01), while the serum TBIL,endotoxin,TNF-α, IL-6 were decreased. MELD score (mean 43.6) predicted 100% deaths within 3 mo before treatment with HBL. After treatment with HBL, four out of 5 patients had decreased MELD scores (mean 36.6). The MELD score predicted 66% mortalities.CONCLUSION: The proinflammatory cytokines (TNFα, IL-6 and endotoxin)can be significantly removed by hybrid bioartificial liver and HBL appears to be effective in blocking SIRS and MODS in patients with acute and sub-acute liver failure. MELD is a reliable measure for predicting short-term mortality risk in patients with end-stage liver disease. The prognostic result also corresponds to clinical outcome.     

乙型肝炎相关慢加急性肝衰竭患者的预后因素分析

目的 探讨影响乙型肝炎相关慢加急性肝衰竭患者预后的危险因素.方法 记录263例乙型肝炎相关慢加急性肝衰竭患者治疗基线时血清胆碱酯酶、白蛋白及胆固醇等反应肝脏储备功能的临床指标及重要并发症的发生情况,并计算其MELD评分.所有患者随访满1年.通过Cox比例风险回归模型筛选出影响预后的独立危险因素.结果 在1年的随访时间内,67例死亡,病死率为25.5％.死亡组血清胆碱酯酶、白蛋白、胆固醇水平均较存活组低.血清胆固醇水平随着MELD值的升高而下降.Cox比例风险回归模型分析得出,肝性脑病、肝肾综合征、上消化道出血、胆固醇≤2.5 mmol/L、MELD评分≥30是影响乙型肝炎相关慢加急性肝衰竭患者预后的独立危险因素,RR分别为6.286、2.983、2.272、2.168及1.853.结论 胆固醇≤2.5 mmol/L、肝性脑病、肝肾综合征、上消化道出血及MELD评分≥30是决定乙型肝炎相关慢加急性肝衰竭患者预后的主要危险因素.     

Indocyanine green clearance test and model for end-stage liver disease score of patients with liver cirrhosis

BACKGROUND:The indocyanine green(ICG)clearance test(clearance rate(K)and retention rate at 15 minutes (R15))is a sensitive indicator to evaluate liver function. The model for end-stage liver disease(MELD)score has emerged as a useful tool for estimating the mortality of patients awaiting liver transplantation and has recently been validated on patients with liver diseases of various etiologies and severity.In this study,we investigated the correlation between the ICG clearance test and MELD score of patient...     

早期病毒学应答对乙型肝炎病毒感染相关肝衰竭患者预后及转归的影响

目的 研究在HBV感染相关肝衰竭抗病毒治疗过程中,早期快速病毒学应答对治疗转归的影响.方法 选择本院2007年6月至2010年12月住院治疗的HBV感染相关肝衰竭患者152例,在内科综合治疗基础上分别予拉米夫定(LAM)或恩替卡韦(ETV)抗病毒治疗.根据抗病毒治疗第4周时患者HBV DNA是否转阴,将患者分为HBV DNA阴性组和HBV DNA阳性组,比较两组治疗基线情况、治疗第4周时TBil、凝血酶原活动度(PTA)、Alb、MELD评分及治疗终点时两组临床转归,对影响治疗转归的所有因素进行多元Logistic逐步回归分析.结果 在治疗第4周时,HBV DNA阴性组TBil水平较HBV DNA阳性组明显降低,两组差异有统计学意义(P=0.000);HBV DNA阴性组PTA较HBV DNA阳性组明显升高,差异有统计学意义(P =0.0001);两组Alb、MELD评分差异无统计学意义.治疗终点时HBV DNA阴性组好转率(74.2％)较HBV DNA阳性组(30.5％)明显升高,差异有统计学意义(x2 =28.15,P=0.0067).对可能影响治疗转归的因素进行多元Logistic回归分析,筛选出有统计学意义的独立危险因素为病情分期和治疗第4周时HBV DNA转阴情况.结论 核苷类似物对病毒的快速抑制作用可提高HBV相关肝衰竭治疗的疗效,改善预后,治疗第4周早期病毒学应答患者预后相对较好.     

91例慢性乙型重型肝炎肝衰竭患者的临床病理分析

目的 观察慢性乙型重型肝炎(CSHB)肝衰竭的临床和病理形态特点.方法 回顾性分析91例CSHB临床和病理资料,按其发病前基础病情分为慢性HBV携带组(HBC)、慢性乙型肝炎组(CHB)和肝硬化组(LC),分析各组患者出现肝衰竭的类型、临床特点和病理特点.结果 91例CSHB患者中,男性74例,女性17例,平均年龄(40.6±11.2)岁,发生在HBC者9例(9.9%)、CHB者7例(7.7%)、LC者75例(82.4%).平均年龄在HBC组为(25.8±6.6)岁、CHB组为(36.9±9.0)岁、LC组为(42.0±10.5),HBC组平均年龄较CHB组和LC组小,P值分别为0.032和0.001.各组患者肝衰竭类型均以哑急性为主,发生肝衰竭时间为15～150d,平均(42.2±30.6)d,以黄疸深、腹水为突出特点.常见诱因为劳累、重叠感染、病毒变异、应用肝损伤药物及饮酒.各组CSHB患者的凝血酶原时间、活动度和总胆红素差异无统计学意义.白蛋白、胆碱酯酶在LC组分别为(30.3±5.1)g/L和(2926.8±1471.1)U/L、HBC组分别为(35.6±5.1)g/L和(4363.5±2063.2)U/L、CHB组分别为(37.4±5.0)g/L和(5167.1±1522.1)U/L,LC组白蛋白、胆碱酯酶均明显低于HBC组和CHB组,F值分别为9.450和9.297,P值均＜0.01.胆固醇LC组为(1.8±1.0)mmol/L、HBC组为(2.9±1.0)mmol/L,LC组低于HBC组,P=0.034,差异有统计学意义.HBV DNA定量HBC组为(6.8±1.7)log10拷贝/ml、LC组为(4.2±2.6)log10拷贝/ml,HBC组高于LC组,P=0.019,差异有统计学意义.HBC和CHB基础上的CSHB肝脏病理表现主要为大块或亚大块坏死,病变较均匀,与急性/亚急性重型肝炎的病理特点并无显著区别,CHB基础上的CSHB,出现广泛坏死时极易掩盖原有病变,Masson染色可显示汇管区周围纤维化.肝硬化基础上者病变不均一,大块或亚大块坏死的同时总有部分结节保留,不同部位坏死范围及新旧程度不一.结论 我国CSHB多发生于肝硬化基础上,其病理特征与慢加急/亚急性肝衰竭相对应,而发生在HBC和CHB基础上的CSHB,其病理特征与急性或亚急性肝衰竭类似.     

Predictors of peri-opertative morbidity and liver dysfunction after hepatic resection in patients with chronic liver disease

BackgroundHepatic resection in patients with chronic liver disease (CLD) is associated with a risk of post-operative liver failure and higher morbidity than patients without liver disease. There is no universal risk stratification scheme for CLD patients undergoing resection.ObjectivesThe aim of the present study was to evaluate the association between routine pre-operative laboratory investigations, model for end-stage liver disease (MELD), indocyanine green retention at 15 min (ICG15) and post-operative outcomes in CLD patients undergoing liver resection.MethodsA retrospective review of patients undergoing resection for hepatocellular carcinoma (HCC) at the University Health Network was preformed. ICG15 results, pre- and post-operative laboratory results were obtained from clinical records. Adjusted odds ratios (AOR) were calculated for associations between pre-operative factors and post-operative outcomes using multivariate logistic regression adjusting for patient age and number of segments resected.ResultsBetween 2001 and 2005, 129 CLD patients underwent surgical resection for HCC. Procedures included 51 (40%) resections of ≤2 segments, 52 (40%) hemihepatectomies and 25 (19%) extended hepatic resections. Thirty- and 90-day post-operative mortality was 1.6% and 4.1%, respectively. Prolonged (>10 days) hospital length of stay (LOS) was independently associated with an ICG15 >15% {AOR [95% confidence interval (CI)]= 8.5 (1.4–51)} and an international normalized ratio (INR) > 1.2 [AOR (95% CI) = 5.0 (1.4–18.6)]. An ICG15 > 15% and MELD score were independent predictors of prolonged LOS. An ICG15 > 15% was also independently associated with MELD > 20 on post-operative day 3 [AOR (95% CI) = 24.3 (1.8–319)].ConclusionsElevated ICG retention was independently associated with post-operative liver dysfunction and morbidity. The utility of ICG in combination with other biochemical measures to predict outcomes after hepatic resection in CLD patients requires further prospective study.A possible role for ICG clearance in predicting outcome following hepatic resection for hepatocellular carcinoma     

Risk factors for progression to acute-on-chronic liver failure during severe acute exacerbation of chronic hepatitis B virus infection

BACKGROUND Acute exacerbation in patients with chronic hepatitis B virus(HBV) infection results in different severities of liver injury. The risk factors related to progression to hepatic decompensation(HD) and acute-on-chronic liver failure(ACLF) in patients with severe acute exacerbation(SAE) of chronic HBV infection remain unknown.AIM To identify risk factors related to progression to HD and ACLF in compensated patients with SAE of chronic HBV infection.METHODS The baseline characteristics of 164 patients with SAE of chronic HBV infection were retrospectively reviewed. Independent risk factors associated with progression to HD and ACLF were identified. The predictive values of our previously established prediction model in patients with acute exacerbation(AE model) and the model for end-stage liver disease(MELD) score in predicting the development of ACLF were evaluated.RESULTS Among 164 patients with SAE, 83(50.6%) had compensated liver cirrhosis(LC),43 had progression to HD without ACLF, and 29 had progression to ACLF within 28 d after admission. Independent risk factors associated with progression to HD were LC and low alanine aminotransferase. Independent risk factors for progression to ACLF were LC, high MELD score, high aspartate aminotransferase(AST) levels, and low prothrombin activity(PTA). The area under the receiver operating characteristic of the AE model [0.844, 95%confidence interval(CI): 0.779-0.896] was significantly higher than that of MELD score(0.690, 95%CI: 0.613-0.760, P < 0.05) in predicting the development of ACLF.CONCLUSION In patients with SAE of chronic HBV infection, LC is an independent risk factor for progression to both HD and ACLF. High MELD score, high AST, and low PTA are associated with progression to ACLF. The AE model is a better predictor of ACLF development in patients with SAE than MELD score.     

Use of the Model for End-Stage Liver Disease (MELD) score to predict 1-year survival of Japanese patients with cirrhosis and to determine who will benefit from living donor liver transplantation

BACKGROUND: Consideration of the prognosis of patients with liver cirrhosis is important when determining the appropriate timing of liver transplantation. Especially in Japan, where 99% of liver transplants are from living donors, timing is very important not only for the patient but also for the family, who need time to consider the various factors involved in living donations. METHODS: To clarify the applicability of the Model for End-Stage Liver Disease (MELD) score in Japanese patients with cirrhosis, changes in the MELD score over 24 months were reviewed in 79 patients with cirrhosis who subsequently died of liver failure (n=33) or who survived 24 months (n=46). All patients had Child class B or C cirrhosis at the start of follow-up. We also compared their survival with that of 30 patients treated by living donor liver transplantation (LDLT) in our institute to determine the proper timing of transplantation in patients with cirrhosis. RESULTS: Significant stratification of survival curves was observed for MELD scores of <12, 12-15, 15-18, and >18 (P=0.0018). A significant survival benefit of LDLT was observed in patients with MELD score >or=15 (P=0.0181), and significantly more risk with transplantation was observed in those with MELD score <15 compared with that of patients in whom the disease followed its natural course (P=0.0168). CONCLUSIONS: MELD score is useful for predicting 1-year survival in Japanese patients with cirrhosis. MELD scores of 15 had discriminatory value for indicating a survival benefit to be gained by liver transplantation and thus can be used to help patients and their families by identifying patients who would benefit from LDLT.     

Indicators and outcome of liver transplantation in acute liver decompensation after flares of hepatitis B

Summary. Non‐cirrhotic patients having acute liver decompensation in flares of hepatitis B can recover spontaneously or die without liver transplantation. Criteria for identifying patients in need of liver transplantation are lacking. Fifty‐one non‐cirrhotic patients having acute liver decompensation in flares of hepatitis B were retrospectively reviewed. The patients were divided into three groups: group A patients (n = 18) recovered from acute liver decompensation spontaneously; group B patients (n = 22) died of acute liver failure; and group C patients (n = 11) had liver transplantation. Model of end‐stage liver disease (MELD) scores were evaluated to identify the criteria for liver transplantation. The cut‐off point of MELD scores for liver transplantation was evaluated by receiver operating characteristic (ROC) curve. Comparing group A and B patients, MELD score was an independent factor to predict prognosis. By analysing ROC curve, a MELD score > 30 was the most optimal cut‐off point to indicate liver transplantation; however, the false positive rate was 11.1%. By weekly measurement of MELD scores, subsequent increase in MELD scores could help to avoid false positives. Moreover, a MELD score > 34 yielded 0% false positive rate and indicated the necessity of definite liver transplantation. For group C patients, ten of 11 patients were saved by liver transplantation. In conclusion, for the patients having acute liver decompensation in flares of hepatitis B, liver transplantation is definitely indicated by MELD scores > 34. Liver transplantation is also indicated if the MELD score increases in the subsequent 1–2 weeks. Liver transplantation has a good outcome if performed on time.