FibroScan评估酒精性肝病肝纤维化程度的诊断价值

目的探讨瞬时弹性成像技术(FibroScan)在评估酒精性肝病肝纤维化程度中的应用价值。方法对60例酒精性肝病患者采用FibroScan测量肝脏硬度,获得FibroScan弹性值(FS值),同时对患者进行肝活组织检查.以病理结果为金标准,分析FS值与酒精性肝纤维化分期的相关性。用受试者工作特征(receiver operatmg charateristic,R()C)曲线评估FibroScan对酒精性肝病的诊断价值。结果酒精性肝病患者肝纤维化分期S0~S4的FS值分别为S0:(5.31±1.06)kPa、S1:(7.91±2.81)kPa、S2:(9.81±3.39)kPa、S3:(14.66±4.31)kPa、S4:(19.81±6.02)kPa。组间差异有统计学意义(P0.(5)。进一步分析显示FS值与肝纤维化分期呈正相关性(r=0.706,P0.05)。肝纤维化程度≥S1、≥S2、≥S3和S4的ROC曲线下面积分别为0.833、0.871、0.906和0.919。结论 Fibroscan作为一种无创技术,能够较准确地定量评估酒精性肝病肝纤维化程度。     

肝脏瞬时弹性超声在药物性肝损伤患者肝纤维化诊断中的作用

目的 探讨肝脏瞬时弹性超声(Fibroscan)在评估药物性肝损伤(DILI)患者肝纤维化程度的价值.方法 上海交通大学医学院附属瑞金医院感染科2009年7月至2011年4月临床诊断为DILI患者54例,在肝活组织检查前1周内运用Fibroscan检测肝平均瞬时弹性超声硬度值(Stiffness),并与按照Ishak评分进行纤维化分期的患者肝组织病理检查结果比对,使用Spearman 等级相关系数方法进行统计学分析,以肝组织检查病理结果为标准绘制Fibroscan受试者工作特征(ROC)曲线,计算ROC曲线下面积(AUC),并计算相应的诊断界值.结果 54例DILI患者中,S0期4例、S1期13例、S2期18例、S3期8例、S4期7例、S5期4例和S6期0例.肝脏纤维化程度与ALT、AST和PLT无明显的统计学关联,而与碱性磷酸酶和TBil水平呈正相关.诊断为DILI患者的肝脏纤维化S0～S5的Stiffness值分别为(6.23±1.78)、(7.24±2.86)、(8.80±5.21)、(20.36±8.73)、(23.14±12.85)和(36.60±30.87) kPa.Stiffness值与其肝纤维化分期呈显著正相关(r=0.633,P＜0.01).以Stiffness值13.25 kPa作为中重度肝纤维化的诊断界值,AUC为0.954,灵敏度为84.2％,特异度为94.3％,阳性预测值为88.89％,阴性预测值为91.67％.结论 Fibroscan可将DILI患者无或轻度肝脏纤维化与中重度纤维化较好地予以区分.     

进食对FibroScan检测乙型肝炎肝纤维化准确性的影响

目的 探讨进食对FibroScan检测乙型肝炎肝纤维化的影响.方法 57例乙型肝炎肝纤维化患者分别于早晨空腹(餐前)和餐后2h(餐后)检测肝脏硬度值,同时行肝脏活体组织检查,以病理结果为“金标准”,分析餐前和餐后肝脏硬度值的差异.结果 餐前和餐后肝脏硬度值差异无统计学意义(P=0.989).病理检查的结果为:餐前FibroScan诊断S2、S3、S4期的受试者工作特征曲线下面积分别为0.93、0.95、0.97,诊断界值分别为8.1、11.0、17.3 kPa;餐后FibroScan诊断S2、S3、S4期的受试者工作特征曲线下面积分别为0.93、0.96、0.95,诊断界值分别为8.0、12.7、16.4 kPa.结论 早晨空腹和餐后2h肝脏硬度值无明显变化,进食对FibroScan检测乙型肝炎肝纤维化无影响.     

Fibroscan在慢性乙型肝炎肝纤维化诊断中的作用及影响因素

目的探讨肝脏瞬时弹性超声成像(Fibroscan,FS)在评估慢性乙型肝炎肝纤维化中的作用及影响因素。方法选择上海瑞金医院感染科2009年1月至2011年12月慢性乙型肝炎(CHB)患者410例,运用FS检测肝脏硬度值(Stiffness值)。所有患者同期行经皮肝穿刺活组织检查,同时检测肝功能、血小板、凝血等指标。以肝活检结果为标准绘制FS工作特征曲线,计算受试者工作特征曲线下面积(AUROC),Stiffness值与Ishak评分比对,运用统计学方法进行分析。结果无肝纤维化(S0期)、轻度肝纤维化(S1～S2期)、中度肝纤维化(S3～S4期)和重度肝纤维化及肝硬化(S5期～S6期)患者Stiffness值(kPa)分别为5.45±1.44、7.01±2.42、9.23±3.00、16.87±6.77,对Stiffness值进行组间比较,差异有统计学意义(P<0.01)。Stiffness值与肝纤维化分期呈显著正相关(r=0.67812,P<0.01)。Fibroscan检测显著肝纤维化和肝硬化的AUROC分别为0.840和0.938,其中以Stiffness值8.050kPa作为显著肝纤维化的诊断界值,敏感度为60.3%,特异度为93.7%,阳性预测值为94.71%,阴性预测值为55.83%;以12.150kPa作为重度肝纤维化和肝硬化的诊断界值点,敏感度和特异度分别为75.9%和92.0%,阳性预测值和阴性预测值分别为61.11%和95.86%。逐步回归统计分析,Alb、PLT、AST、年龄、体质量对Stiffness值有影响。结论 Fibroscan评估CHB患者肝纤维化程度尤其是显著肝纤维化和肝硬化准确性高,在诊断与疗效评估中具有较好的应用价值。     

FibroScan对慢性药物性肝损害肝纤维化的诊断价值研究

目的 探讨FibroScan对于慢性药物性肝损害(drug-induced liver injury,DILI)肝纤维化的诊断准确性.方法 选择2009年4月-2011年1月在我院住院的经肝脏穿刺病理诊断的慢性DILI患者49例,进行FibroScan检测得到肝脏硬度测量(liver stiffness measurement,LSM)值.以肝脏活体组织检查病理结果为“金标准”绘制受试者工作特征(receiver operating characteristic,ROC)曲线,计算ROC曲线下面积(area under the receiver operating characteristic curve,AUROC),以评价FibroScan对慢性DILI肝纤维化的诊断价值.结果 LSM值与肝脏病理分期呈正相关,Kendall相关系数为0.607,P＜0.001.FibroScan诊断慢性DILI肝纤维化≥S2期、≥S3期、S4期的AUROC分别为0.878、0.944、0.993.结论 FibroScan对诊断慢性DILI肝纤维化程度有较好的准确性.     

瞬时弹性超声成像在评价乙型肝炎肝纤维化严重程度中的价值

目的探讨瞬时弹性超声成像在评价乙肝肝纤维化严重程度中的价值。方法选取我院2015年1月至2016年6月期间收治的220例慢性乙肝患者在肝脏穿刺活检,根据肝脏穿刺纤维化的结果分为5组,分别为S0组(45例)、S1组(42例)、S2组(50例)、S3组(41例)、S4组(42例),同时在肝穿1周内运用瞬时弹性成像对肝硬度值(LSM)进行检测。比较5组患者肝硬度值的差异,分析肝硬度值(LSM)和肝纤维化严重程度的关系,并绘制受试者工作特性曲线(ROC),并计算瞬时弹性超声成像在诊断肝纤维化程度的特异度和灵敏度。结果①5组患者肝硬度值的比较:5组患者肝硬度值分别为[(4.97±1.45)、(7.14±1.36)、(9.05±1.51)、(11.43±1.32)、(13.17±1.65)kPa],S0期的肝硬度值最低,S4期肝硬度值最高,组间比较均具有统计学差异(均P0.05)。②肝硬度值(LSM)与肝纤维化分期的相关性:肝硬度值随着肝纤维化分期的升高而不断升高,肝硬度值与肝纤维化分期呈正相关(r=0.668,P=0.003)。③肝硬度值诊断肝纤维化程度的特异度和灵敏度:肝硬度值诊断S1、S2、S3、S4期纤维化的曲线下面积(AUC)分别为0.754、0.863、0.902、0.927;诊断的临界值分别为(6.24、7.61、9.06、10.46)kPa,特异度分别为81.2%、77.5%、94.3%、97.8%;灵敏度分别为71.2%、74.6%、86.2%、87.9%。结论瞬时弹性成像在评价慢性乙肝患者肝纤维化严重程度中有重要价值,特别是针对S3期以上的肝纤维化,具有较高的特异度和灵敏度。     

FibroScan对慢性乙型肝炎肝纤维化诊断的临床价值

目的探讨肝脏瞬时弹性扫描仪(FibroScan)对慢性乙型肝炎(chronic hepatitis B,CHB)肝纤维化的诊断价值。方法对80例行肝脏穿刺检查的CHB患者进行FibroScan检测,记录所检测到的肝脏硬度值。肝纤维化程度分为无或轻度肝纤维化(S0~S1期)、显著肝纤维化(S2~S4期)、严重肝纤维化(S3~S4期)和早期肝硬化(S4期)。以肝脏活体组织检查病理结果为"金标准",绘制受试者工作特征曲线(receiver-operating characteristic curve,ROC曲线),计算ROC曲线下面积(area under ROC curve,AUROC),评价FibroScan对CHB患者肝纤维化的诊断价值。结果肝脏硬度值与肝脏病理分期呈正相关(rs=0.739,P0.01)。FibroScan对显著肝纤维化、严重肝纤维化和早期肝硬化的AUROC值分别为0.865、0.940和0.944。结论 FibroScan可以较准确地估计CHB患者的肝纤维化程度,部分替代有创性的肝脏活体组织检查,对CHB患者肝纤维化的诊断和治疗有指导意义。     

二维剪切波弹性成像诊断慢性乙型肝炎患者肝纤维化价值研究

目的 探讨采用二维剪切波弹性成像(2D-SWE)技术检查慢性乙型肝炎(CHB)患者,不同取值方法获得的肝脏弹性模量值诊断肝纤维化的效能差异。方法 2019年10月～2022年6月我院诊治的72例CHB患者,行肝活检,根据Scheuer评分将肝纤维化程度分为S0～S4,以Scheuer评分≥S2为显著性肝纤维化。使用Supersonic Aixplorer型彩色多普勒超声诊断仪行2D-SWE检查,分别以5次测量的中位数(方法一)或均值(方法二)为最终检查值。应用受试者工作特征曲线(ROC)并计算曲线下面积(AUC)评估两种取值方法获得的弹性模量值诊断CHB患者肝纤维化和显著性肝纤维化的效能。结果 根据Scheuer评分,肝组织学检查发现肝纤维化S0/S1期31例、S2期19例、S3期12例和S4期10例,其中S2～S4期显著性肝纤维化41例;取值方法一检测的S0/S1、S2、S3和S4期肝脏弹性模量值分别为(6.1±1.2)kPa、(8.1±1.1)kPa、(11.5±1.8)kPa和(20.9±2.5)kPa,与取值方法二检测的(6.0±1.1)kPa、(8.3±1.2)kPa、(11...     

FibroScan对原发性胆汁性肝硬化患者肝纤维化的诊断价值

目的探讨FibroScan对于原发性胆汁性肝硬化（primary biliary cirrhosis,PBC）肝纤维化诊断的准确性。方法选择2009年10月—2013年12月经肝脏穿刺病理诊断的PBC患者56例,进行FibroScan检测得到肝脏硬度测量（liver stiffness measurement,LSM）值。以肝脏活组织检查结果作为＂金标准＂,计算受试者工作特征曲线下面积（AUROC）,评价FibroScan对PBC肝纤维化的诊断价值。结果 LSM值平均为（13.714±7.475）kPa,与肝脏病理分期呈正相关,Kendall相关系数为0.897,P〈0.01。FibroScan诊断PBC肝纤维化≥S2期、≥S3期、S4期的AUROC分别为0.897、0.959、0.989。纤维化分期为≥F2、≥F3、F4时对应的最佳截断值分别为12.9、16.1和19.7 kPa。肝硬度、血清透明质酸、AST/PLT（APRI）均为肝脏病理分期独立相关因素。结论 FibroScan是一项方便、准确的用于诊断PBC肝纤维化程度的方法。     

慢性乙型肝炎肝纤维化患者实时剪切波弹性成像的应用价值分析

目的探讨实时剪切波弹性成像技术(shear wave elastography,S W E)与常规超声检查在评估慢性乙型肝炎患者肝纤维化中的应用价值.方法回顾性分析唐山市传染病医院在2015-08/2017-06收治的慢性乙型肝炎患者87例,分别进行常规超声和S W E检查,以病理穿刺活检结果为金标准,分析常规超声、SWE与肝纤维化病理分期的相关性,评估常规超声、SWE诊断肝纤维化各分期的ROC曲线下面积,比较常规超声与SWE在诊断肝纤维化各分期的诊断效能.结果 (1)常规超声积分在肝纤维化相邻分期之间(S0-S1vs S2,S2 vs S3,S3 vs S4)比较差异无统计学意义(P=0.451,0.639,0.103);但不相邻分期(S0-S1 vs S3,S0-S1vs S4,S2 vs S4)之间常规超声评分比较差异具有统计学意义(P=0.001,0.000,0.000);SWE在不同肝纤维化分期的弹性模量值分别为(S0=5.625 kPa±1.221 kPa,S1=7.172 k Pa±1.818 k Pa,S2=10.295 kPa±3.122kPa,S3=15.541 kPa±4.340 kPa,S4=23.918 kPa±5.697 kPa),肝脏弹性模量在相邻及不相邻分期之间比较差异均具有统计学意义(P均0.05);(2)Spearman相关性分析显示,常规超声积分、SWE弹性模量值与肝纤维化分期之间存在正相关(r=0.529,0.798,P均0.001);SWE弹性模量值与肝纤维化之间相关系数高于常规超声积分;(3)常规超声积分在诊断肝纤维化S≥2、S≥3和S4期的ROC曲线下面积分别为0.766,0.891,0.764;SWE值在诊断肝纤维化S≥2、S≥3和S4期的ROC曲线下面积分别为0.941,0.948,0.952;SWE的诊断效能高于常规超声(P0.05).结论相比于常规超声,SWE技术在评估慢性乙型肝炎患者肝纤维化程度方面具有更高的应用价值,可重复性好,具有较高的潜在临床价值.     

Ultrasound liver elastography beyond liver fibrosis assessment

Several guidelines have indicated that liver stiffness(LS) assessed by means of shear wave elastography(SWE) can safely replace liver biopsy in several clinical scenarios, particularly in patients with chronic viral hepatitis. However, an increase of LS may be due to some other clinical conditions not related to fibrosis,such as liver inflammation, acute hepatitis, obstructive cholestasis, liver congestion, infiltrative liver diseases. This review analyzes the role that SWE can play in cases of liver congestion due to right-sided heart failure, congenital heart diseases or valvular diseases. In patients with heart failure LS seems directly influenced by central venous pressure and can be used as a prognostic marker to predict cardiac events. The potential role of LS in evaluating liver disease beyond the stage of liver fibrosis has been investigated also in the hepatic sinusoidal obstruction syndrome(SOS) and in the Budd-Chiari syndrome. In the hepatic SOS, an increase of LS is observed some days before the clinical manifestations;therefore, it could allow an early diagnosis to timely start an effective treatment.Moreover, it has been reported that patients that were successfully treated showed a LS decrease, that reached pre-transplantation value within two to four weeks. It has been reported that, in patients with Budd-Chiari syndrome, LS values can be used to monitor short and long-term outcome after angioplasty.     

Recurrent nonviral liver disease following liver transplantation

Recurrent disease after liver transplantation is well recognized and remains a potential cause of premature graft loss. The rates of recurrence are difficult to establish because of the lack of consistency in diagnostic criteria and approaches to diagnosis. Owing to the fact that recurrent parenchymal disease may occur in the presence of normal liver tests, those centers that use protocol biopsies will report greater rates of recurrence. It is important to recognize that rates of recurrence vary according to indication and show little correlation with rates of graft loss from recurrent disease. Recurrance rates are greatest for primary sclerosing cholangitis and autoimmune hepatitis, and low reccurrance rates are reported for alcoholic liver disease and recurrent primary biliary cirrhosis. The impact of recurrent nonalcoholic fatty liver disease is not yet clear. Patients and clinicians need to be aware of the possibility of recurrent disease in the differential diagnosis of abnormal liver tests, and management stategies may require alteration to reduce the impact of disease recurrence on outcome. Finally, an understanding of which diseases do recur after transplantation and identification of the risk factors may lead to a better understanding of the pathogenetic mechanisms of these conditions.     

中国肝癌肝移植的现状与展望

肝癌行肝移植治疗的指征、效果和相关问题一直存在争论,国际上已经有数个通用的肝癌肝移植标准,如Milan标准、Pittsburgh标准、UCSF标准等等,中国的移植学家们也在纷纷探讨适合中国的肝癌肝移植标准.本文收集并分析近年来国内外的文献,结合本移植中心460例肝移植的病例,对肝癌的分期标准、晚期肝癌行肝移植的指征进行了探讨,笔者认为影响我国肝癌肝移植的主要因素有:供肝的来源、术后乙肝及肿瘤的复发及相关社会因素等.     

Chronic liver diseases as liver tumor precursors

Liver cancer is a major global health problem and hepatocellular carcinoma (HCC) accounts for 75% of all liver carcinoma. HCC occurs more often in men than in women and mostly in people 50 to 60 years old. The disease is more common in parts of sub-Saharan Africa and Asia than in North and South America and Europe. Nevertheless its incidence increased over the past 4 decades in some Western countries. Worldwide, liver carcinoma is the 5th most common cancer and 3rd most common cause of cancer mortality (behind only lung and colorectal cancer) with approximately 680,000 annual deaths. Unlike most of the other malignancies, HCC almost entirely develops in the context of inflammation and organ injury and is related to cirrhosis in about 85% of the cases. Among underlying etiologies of liver cirrhosis, most frequent are viral infection and toxic substances, mostly alcohol. The main HCC risk factor in Eastern Asia and Africa is hepatitis B virus infection. Hepatitis C virus infection is the main risk factor in Western countries. Hereditary hemochromatosis is not a very frequent cause of liver cirrhosis, but these patients are at higher risk for HCC compared with other etiologies of cirrhosis. Aflatoxins, cancer-causing substances made by a type of plant mold, can play a role in some countries in Asia and Africa, and can have a synergistic effect with hepatitis B infection.     

Fatty liver in liver transplantation and surgery

Steatosis of the liver is common in Western countries, affecting about 25% of donors for liver transplantation and 20% of patients undergoing liver resection. Transplantation of livers with severe steatosis (> 60%) is associated with a high risk of primary nonfunction, and these livers should not be used for organ donation. In contrast, transplantation with livers containing mild steatosis (< 30%) yields results similar to those of transplantation performed with nonfatty livers. The outcome of livers with moderate steatosis (30 to 60%) are varying, and the use of these organs depends on the existence of additional risk factors. Similarly, liver resection in patients with steatosis is associated with a risk of postoperative mortality when compared with patients with nonfatty livers (14% versus 2%). Although hepatic steatosis is an important risk factor for surgery, little is known about the mechanisms of injury. In animal experiments, steatosis is associated with decreased ATP production and a disturbance of sinusoidal flow. Further contributing factors may include Kupffer cell dysfunction and leukocyte adhesion. Fatty hepatocytes have reduced tolerance against ischemic injury with a predominant necrotic form of cell death. In addition, the ability of hepatocytes to regenerate after major tissue loss is impaired in the steatotic liver. Very few protective strategies are known. Ischemic preconditioning and intermittent clamping protect the human liver against prolonged periods of ischemia. These techniques appear to be particularly protective in the steatotic liver. New insights into the mechanisms of liver failure in steatotic organs are needed to decrease the risk of surgery and increase the pool of organ donors.     

Orthotopic liver transplantation for alcoholic liver disease

Alcohol abuse is the most common cause of end-stage liver disease in the United States, but many transplant centers are unwilling to accept alcoholic patients because of their supposed potential for recidivism, poor compliance with the required immunosuppression regimen and resulting failure of the allograft. There is also concern that alcohol-induced injury in other organs will preclude a good result. From July 1, 1982, to April 30, 1988, 73 patients received orthotopic liver transplants at the University of Pittsburgh for end-stage alcoholic liver disease. Fifty-two (71%) of these were alive at 25 +/- 9 mo (mean +/- S.D.) after transplantation, when a phone survey of these patients, their wives/husbands, and their physicians was performed to evaluate their subsequent use of alcohol, current medical condition and employment. Data obtained were compared with those for nonalcoholic patients selected as transplant controls. The recidivism rate has been 11.5%, with most patients drinking only socially. Fifty-four percent of the survivors are employed, 21% classify themselves as homemakers and only 11 (21%) are unable to work. Twenty-one patients died after transplantation; the most frequent cause of death was sepsis (43%), and intraoperative death was the next most common cause (28.6%). These data demonstrate that alcoholic patients can be transplanted successfully and achieve good health not significantly different from that of individuals transplanted for other causes. Thus orthotopic liver transplantation is a therapeutic option that should be considered for individuals with end-stage alcoholic liver disease who desire such therapy.     

Adult liver transplantation for metabolic liver disease

Liver replacement provides an effective method of replacing a failing liver, and corrects the underlying defect in many metabolic conditions. Results of liver transplantation for metabolic diseases have been encouraging, with the exception of hereditary hemochromatosis, in which infectious and for which cardiac complications appear to increase posttransplant mortality. An improved understanding of the underlying genetic and molecular defect will lead to advances in medical therapy and perhaps will decrease the need for liver replacement. The prospects of gene therapy are being pursued for many metabolic disorders, however until this research leads to direct clinical application, liver transplantation remains the only effective option for many patients with metabolic liver disease.