中西医结合治疗乙型肝炎慢加急性肝功能衰竭临床研究

目的:观察茵虎退黄方治疗乙型肝炎慢加急性肝功能衰竭(hepatitis B virus-acute on chronic liver failure,HBV-ACLF)患者的临床疗效。方法:采用随机对照试验设计方案,将符合纳入标准的68例患者随机分为治疗组和对照组,每组34例。对照组采用西医常规疗法:(1)营养支持疗法:血浆白蛋白低于30 g·L-1者,给予同型血浆200 m L、体积分数20%人血白蛋白50 m L(两者交替应用),均每周2次,静脉滴注。(2)保肝治疗:给予复方甘草酸苷注射液100 m L,注射用促肝细胞生长素120μg,分别加入体积分数5%葡萄糖注射液250 m L,静脉滴注,每日1次。(3)抗病毒治疗:恩替卡韦分散片0.5 mg,口服,每日1次。(4)人工肝支持治疗(血浆置换):每次置换新鲜同型血浆2 000 m L,每周1次,若血清总胆红素低于正常高限值10倍,即停止人工肝治疗。(5)并发症防治:合并感染者及时应用抗生素控制感染,积极预防肝性脑病、肝肾综合征及上消化道出血等并发症。治疗组在对照组治疗基础上加用茵虎退黄方(茵陈45 g,虎杖30 g,赤芍30 g,茯苓30 g,猪苓20 g,炒白术20 g,郁金20 g,车前子30 g,玉米须30 g)治疗。腹部胀满甚者加大腹皮30 g,炒莱菔子30 g;纳差者加焦山楂、焦神曲、焦麦芽各20 g,焦谷芽20 g,便秘甚者加麻子仁30 g,生大黄9 g;有齿鼻衄血或皮下瘀斑者,加仙鹤草30 g,三七3 g;有神志异常者加服安宫牛黄丸,每日1丸。以上中药配方颗粒由深圳三九医药贸易有限公司提供。两组患者均以2个月为1个疗程。观察两组患者治疗前后症状体征、血清肝功能指标如总胆红素(serum total bilirubin,TBIL)、谷丙转氨酶(glutamic pyruvic transaminase,ALT)、谷草转氨酶(glutamic-oxalacetic transaminase,AST)、血清白蛋白(blood albumin,ALB)、前白蛋白(prealbumin,PA)等指标改善情况,以及其他生化学指标如凝血酶原活动度(prothrombin activity,PTA)、血氨(blood ammonia,AMON))、内毒素(endotoxin,LPS)、肿瘤坏死因子-α(Tumor necrosis factor alpha,TNF-α)及白细胞介素-6(Interleukin-6,IL-6)水平变化情况。结果:(1)两组患者临床疗效比较:治疗组显效22例,有效6例,无效5例,有效率为85.29%;对照组显效14例,有效7例,无效11例,有效率为67.65%,两组比较,差异有统计学意义(P0.05);(2)两组实验室指标比较:治疗后两组肝功能及凝血功能指标均较治疗前明显好转,差异有统计学意义(P0.05);(3)治疗后两组AMON、LPS、TNF-α及IL-6水平均较治疗前明显改善,且治疗组疗效优于对照组,差异有统计学意义(P0.05);(4)两组患者并发症发生率、人工肝治疗次数及住院治疗时间比较,治疗组均优于对照组,差异有统计学意义(P0.05)。结论:中西医结合治疗能够提高HBV-ACLF患者生存率,减少并发症的发生及人工肝治疗次数,缩短患者住院治疗时间。其作用机制与降低患血氨、内毒素水平及减少炎性细胞因子(TNF-α、IL-6)释放,从而阻断肝细胞进一步损伤、促进者肝脏功能恢复等因素有关。

Clinical Study on Combination of Chinese and Western Medicine Treatment of Hepatitis B Virus-Acute on Chronic Liver Failure

Objective:To observe the clinical effect of Yin Hu Tui Huang Fang treatment of hepatitis B virus-acute on chronic liver failure(HBV-ACLF).Methods:68 patients were randomly divided into the treatment group and the control group (n =34).The control group received conventional treatment,①Nutritional support therapy:serum albumin less than 30g · L-1 patients,given the same type of plasma 200mL,the volume fraction of 20％ Human Albumin 50 mL (two alternate applications),2 times a week,intravenous drip.②Liver protection treatment:Compound Glycyrrhizin Injection 100 mL,Hepatocyte Growth-promoting Factor for Injection 120 μg,separately adding volume fraction 5％,Glucose Injection 250 mL,intravenous drip,1 time a day.③Antiviral treatment:Entecavir Dispersible Tablets 0.5 mng,oral,1 time a day.4④Artificial liver support therapy (plasma exchange):each replacement of fresh plasma 2000 mL,one time a week,if serum total bilirubin is less than 10 times of the normal high limit,that is,stop artificial liver treatment.⑤Prevention of complications:timely application of antibiotics to control infection accompanied,prevention of hepatic encephalopathy,hepatorenal syndrome and upper gastrointestinal bleeding and other complications.and the treatment group based on routine treatment of Western medicine combined with Yin Hu Tui Huang Fang,composition:Yinchen (Capillary Artemisia) 45 g,Huzhang (Polygonum Cuspidatum) 30 g,Fuling (Poria Cocos) 30 g,Zhuling (Grifola) 20 g,Chaobaizhu (Fried Atractylodes Macrocephala Koidz) 20 g,Yujin (Radix Curcumae) 20 g,Cheqianzi (Semen Plantaginis) 30 g,Yumixu (Stigma of Corn) 30 g.Abdominal fullness obviously addition Dafupi (Pericarpium Arecae) 30 g,Chaolaifuzi (Fried Radish Seed)30g;anorexia plus Jiaoshanzha(Scorched Hawthorn Fruit) 20 g,Jiaoshenqu (Medicated Leaven)20g,Jiaomaiya (Caramel Malt) 20 g,Jiaoguya (Rice Sprout) 20 g,serious constipation addition Maziren (Semen Cannabidis) 30 g,Shengdahuang (Raw Rhubarb) 9 g;gingival hemorrhage,epistaxis or ecchymosis,plus Xianhecao (Hairyvein Agrimony) 30 g,Sanqi (Pseudo-Ginseng) 3 g.Abnormal mind plus take Angongniuhuang pill,1 pill per day.Chinese medicine granule provided by Shenzhen 39 Pharmaceutical Trading Company Limited.Two groups were treated for 2 months for 1 course,two groups were observed before and after treatment in patients with liver function index of symptoms and signs,such as serum total bilirubin (TBIL),alanine aminotransferase(ALT),aspartate aminotransferase (AST),serum albumin (ALB),prealbumin (PA) to improve the situation,and other biochemical indicators such as prothrombin activity (PTA),blood ammonia (AMON)),endotoxin (LPS),tumor necrosis factor alpha (TNF-oα) and interleukin6 (IL-6) level changes.Results:①In the treatment group,22 cases were markedly effective,6 cases effective,5 cases ineffective,the efficiency was 85.29％;in the control group,14 cases were markedly effective,7 cases effective,11 cases ineffective,the efficiency was 67.65 ％,and the difference was statistically significant (P ＜ 0.05).②Two groups of liver function and blood coagulation function (PTA) index comparison:after treatment,the liver function and coagulation function index of the two groups were significantly improved compared with before treatment,the treatment group was better than the control group(P ＜ 0.05).③Comparison of other biochemical indicators:AMON,LPS,TNF-α and IL-6 levels were significantly improved after treatment in two groups,the treatment group was better than the control group(P ＜ 0.05).④The two groups of patients with complications,artificial liver treatment times and hospitalization time,the treatment group was better than the control group (P ＜ 0.05).Conclusion:Combination of Chinese and Western medicine can improve the survival rate of HBV-ACLF patients,and reduce the occurrence of complications of artificial liver treatment times,shorten treatment time and reduce hospitalization;blood ammonia and endotoxin levels and reduce inflammatory cytokines and its mechanism (TNF-α,IL-6) release,thereby blocking thc liver cell injury and promote the recovery of liver the function of patients with other factors.