防微杜渐,关注肝衰竭前期诊疗

肝衰竭病情重、进展快、病死率甚高,在肝衰竭发生前期进行早期预警,早期干预,对改善患者预后至关重要。目前关于肝衰竭前期的诊断标准尚不统一,关于肝衰竭前期的研究主要集中在乙型肝炎相关肝衰竭人群中进行,现就目前肝衰竭前期早期诊断、预警及治疗展开讨论。     

急性肝衰竭早期预警及预后评估

急性肝衰竭病情危重、救治十分困难、病死率极高。对急性肝衰竭预后进行早期预警是提高生存率的关键。尽管急性肝衰竭预后评估较困难,但这种评估对于优化临床治疗路径、特别是适时选择肝移植等具有十分重要的临床价值。本文首先评价了一慢性乙型肝炎严重急性加重”在早期预警急性肝衰竭发生风险中的价值;其次．提出了“急性肝衰竭前期”的概念、诊断标准及其在早期预警急性肝衰竭发生风险中的价值;最后,对常见的肝衰竭预后评估系统或模型的优缺点作了简要介绍。     

乙型肝炎肝衰竭的早期预警及预后评价

乙型肝炎肝衰竭临床表现十分复杂,病死率高,其早期诊断与治疗对患者的预后具有重要影响。回顾了目前有关乙型肝炎肝衰竭发生、发展的预警和预后评估指标,期望有助于提高该重症肝病的早期诊断水平,从而改善患者的预后。     

慢加急性肝衰竭早期预警及中西医结合治疗特色优势

慢加急性肝衰竭起病急骤,病情凶险,病死率高。对于慢加急性肝衰竭强调早期预警、动态评估病情、预后评价等全病程管理。诊疗应重视去除病因、防治并发症、器官支持和中医药干预。本文评述慢加急性肝衰竭的定义、发病机制、预警、预后评分和中西医结合治疗优势,旨在为疾病的早期识别、预后判断和中西医结合临床治疗提供借鉴。     

肝衰竭前期的人工肝治疗

肝衰竭是临床最常见的严重肝病临床症候群,进展快,病死率高。在肝衰竭发生前期或“黄金窗口期”进行早期干预对于改善患者预后具有重要意义。关于肝衰竭前期的研究主要集中于HBV相关慢加急性肝衰竭或酒精相关慢加急性肝衰竭。现就目前肝衰竭前期的发生机制及人工肝治疗展开讨论,旨在指导临床更加合理、有效地应用人工肝技术,推动相关研究,从而降低肝衰竭患者的病死率。     

肝衰竭前期的预警及治疗研究进展

肝衰竭前期患者肝功能急剧恶化,存在发生肝衰竭的风险,病死率较高。现就肝衰竭前期概念,特别是肝衰竭前期发展为肝衰竭的预警研究及治疗进展进行综述,以期加强临床医师对肝衰竭前期的重视,促进肝衰竭防治关口前移,提高肝衰竭救治成功率。     

肝衰竭并发急性肾损伤热点研究新进展

急性肾损伤(AKI)定义为肾小球滤过率急剧下降和血清肌酐的急骤升高,是肝衰竭患者的严重并发症之一。早期诊断及处理对降低病死率、改善肝衰竭预后极为重要。对肝衰竭患者AKI的诊断标准、发病机制、生物标志物、临床特点及治疗的研究进展进行阐述。指出对AKI的定义、分期不断修正,研发高效的肾损伤生物标记物,是未来研究的方向。     

肝衰竭合并侵袭性肺曲霉病临床分析

目的探讨肝衰竭患者合并侵袭性肺曲霉病（IPA）的临床特点及治疗对策。方法对我中心341例肝功能衰竭合并肺部感染患者的临床资料进行回顾性分析。结果组织病理诊断明确的IPA11例,临床诊断病例3例。肺部IPA主要诱因为长期应用广谱抗生素和糖皮质激素;临床症状和影像学变化非特异性和不典型;及时诊断并及时使用卡泊芬净治疗,可以减少IPA患者的病死率。结论对肝衰竭患者需要提高早期诊断、治疗IPA的意识。     

肝功能衰竭的诊断和治疗现状

肝功能衰竭(简称肝衰竭)是临床常见的严重肝病症侯群,其预后不良,病死率甚高(可达50%～90%),严重威胁人类健康,也是临床医师最具挑战的疾病之一。多年来,各国学者对肝衰竭的定义、分类、诊断和治疗等问题不断进行探索,但迄今尚无一致意见,而临床对肝衰竭的认识、早期正确的诊断和治疗对于救治肝衰竭患者尤为重要。本文拟就肝衰竭的诊断和治疗进展作一综述。肝功能衰竭的定义和病因[1]定义肝衰竭是由多种病因引起的严重肝损伤,表现肝脏合成、代谢、排泄和解毒等功能严重障碍和失代偿,出现以黄疸、凝血功能障碍、肝性脑病和腹水等为主要表现的…     

进一步加强肝衰竭的临床与基础研究

肝衰竭是临床常见的严重肝病临床症候群,病死率高。近些年来肝衰竭的研究虽然已经取得了很大进展,但仍然有不少问题尚存在一些分歧,如肝衰竭的分类、诊断标准及治疗等,发病机制需要进一步阐明,新的诊治策略需要进一步探索。因此,需要进一步加强肝衰竭的临床与基础研究,从而提升肝衰竭的综合诊治水平,不断降低肝衰竭病死率。     

Advances in cell death - related signaling pathways in acute-on-chronic liver failure

Acute-on-chronic liver failure (ACLF) has been a hot spot in the field of liver disease research in recent years, with high morbidity, rapid course change and high mortality. Currently, there is the absence of specific treatment in clinical practice. Liver transplantation has the best therapeutic effect, but it is prone to have internal environment disorder and liver cell death after transplantation, which leads to the failure of transplantation.In recent years, with the development of molecular biology, scholars have explored the treatment of ACLF at the molecular level, and more and more molecular signaling pathways related to the treatment of ACLF have been discovered. Modulating the relevant signaling pathways to reduce the mortality of liver cells after transplantation may effectively improve the success rate of transplantation. In this review, we introduce some signaling pathways related to cell death and their research progress in acute-on-chronic liver failure.     

Recurrence of diseases following orthotopic liver transplantation

Long-term graft survival and mortality after liver transplantation continue to improve. However, disease recurrence remains a major stumbling block, especially among patients with hepatitis C. Chronic hepatitis C recurs to varying degrees in nearly all patients who undergo transplantation. Transplantation for hepatitis C is associated with higher rates of graft failure and death compared with transplantation for other indications, and retransplantation for hepatitis C related liver failure remains controversial. Recurrence of hepatitis B has been markedly reduced with improved prophylactic regimens. Further, rates of hepatocellular carcinoma recurrence have also decreased, as improved patient selection criteria have prioritized transplantation for those with a low risk of recurrence. Primary biliary cirrhosis recurs in some patients, but it is often relatively mild. Autoimmune liver disease has also been shown to have a relatively benign post-transplantation course, but some studies have indicated that it slowly progresses in most recipients. It has been recently reported that alcoholic liver disease liver transplant recipients who return to drinking have worsened mortality. In such patients worse outcomes are not due to graft failure, but instead to other comorbidities. Recurrences of other diseases, including nonalcoholic steatohepatitis and primary sclerosing cholangitis, are now being recognized as having potentially detrimental effects on graft survival and mortality. Expert clinical management may help prevent and treat complications associated with disese recurrence.     

肝衰竭合并侵袭性真菌病的诊断策略

肝衰竭患者发生侵袭性真菌病(IFD)的危险性增加,致死率增加,早期诊断、及时治疗是改善预后的关键。笔者梳理了肝衰竭合并IFD的流行情况及危险因素、肝衰竭患者的早期识别、肝衰竭合并IFD的诊断、中医对肝衰竭合并真菌感染的认识等内容。肝衰竭患者凝血机制差,获取病理确诊较为困难,详细分析患者的危险因素、早期识别临床特征、及时进行血液/体液微生物学检测是早期诊断的重要策略。     

Artificial extracorporeal liver support therapy in patients with severe liver failure

Severe liver failure is common and carries a high mortality risk in patients with both acute and acute-on-chronic liver failure. The failing liver constitutes a medical emergency, and in many cases liver transplantation is the only definite treatment. Extracorporeal liver support can be employed as a strategy for bridging to transplantation or recovery. This article focuses on options for artificial (nonbiological) extracorporeal treatment: single-pass albumin dialysis, fractionated plasma separation and adsorption (Prometheus^®) and the molecular adsorbent recirculatory system. Their different principles, potential advantages and indications are discussed. Despite proven biochemical efficacy, there are little data regarding clinical end points. Thus far, molecular adsorbent recirculatory system therapy in acute and acute-on-chronic liver failure showed no survival benefit compared with standard medical therapy. Prometheus therapy showed reduced mortality in subgroups of higher severity of disease compared with standard medical therapy. Nevertheless, the value of extracorporeal liver support remains to be corroborated by further clinical studies that include the optimal timing, mode, intensity and duration of this treatment.     

Early intervention and intensive management of patients with diabetes,cardiorenal, and metabolic diseases

Increasing rates of obesity and diabetes have driven corresponding increases in related cardiorenal and metabolic diseases. In many patients, these conditions occur together, further increasing morbidity and mortality risks to the individual. Yet all too often, the risk factors for these disorders are not addressed promptly in clinical practice, leading to irreversible pathologic progression. To address this gap, we convened a Task Force of experts in cardiology, nephrology, endocrinology, and primary care to develop recommendations for early identification and intervention in obesity, diabetes, and other cardiorenal and metabolic diseases. The recommendations include screening and diagnosis, early interventions with lifestyle, and when and how to implement medical therapies. These recommendations are organized into primary and secondary prevention along the continuum from obesity through the metabolic syndrome, prediabetes, diabetes, hypertension, dyslipidemia, nonalcoholic fatty liver disease (NAFLD), atherosclerotic cardiovascular disease (ASCVD) and atrial fibrillation, chronic kidney disease (CKD), and heart failure (HF). The goal of early and intensive intervention is primary prevention of comorbidities or secondary prevention to decrease further worsening of disease and reduce morbidity and mortality. These efforts will reduce clinical inertia and may improve patients' well-being and adherence.     

抗结核药物相关性肝功能衰竭34例临床特征

目的分析抗结核药物诱发肝功能衰竭的临床特征及相关影响因素。方法回顾性分析34例抗结核药物治疗期间出现肝功能衰竭的病例资料,按≤35岁、36～55岁及>56岁3个年龄段进行临床特征及相关影响因素分析。采用χ~2检验进行统计分析。结果 34例抗结核药物性肝功能衰竭中男15例,女19例,年龄14～68岁,平均(38.2±10.5)岁;病死率为67.6%(23/34),而超急性肝功能衰竭(2例)和急性肝功能衰竭(8例)中女性7例,病死8例;≥56岁者11例全部为亚急性肝功能衰竭,死亡9例,与≤55岁患者比较,差异有统计学意义(P<0.01)。所有病例初始治疗为异烟肼、利福平、吡嗪酰胺联用,治疗至诊断为药物性肝功能衰竭(DILF)的时间为5～56 d(平均23 d)。34例中HBsAg阳性8例,3例HBsAg/抗-HBe阳性患者应用激素后1例HBeAg转为阳性,2例HBV DNA由低于检测下限出现高于检测下限;HBV血清标志物阳性者死亡率(6/8,75%)与阴性者死亡率(17/26,65.4%)比较,差异有统计学意义(P<0.05)。结论抗结核药物诱发的超急性肝功能衰竭和急性肝功能衰竭可能与遗传多态性及机体较强的免疫状态相关;亚急性肝功能衰竭则可能与老年人药物在肝脏代谢能力的改变相关;激素有增加HBV复制的可能性,与肝功能衰竭的预后相关。     

心力衰竭生物标记物的研究进展

心力衰竭是一种复杂的临床综合征,随着人口老龄化和心血管疾病治疗水平的提高,疾病死亡率在逐步下降,同时心力衰竭患者的数量在进一步增长。目前临床上对心力衰竭的诊断存在一定的局限性,这些局限性需要我们通过对新的生物标记物监测来克服和完善。本文就目前发现的几项在临床上运用潜力较大的几种标记物进行探讨。     

Liver failure and mortality in HIV-positive haemophiliacs: FOURTEEN-YEAR EXPERIENCE AND LITERATURE REVIEW

Progression to clinical liver failure has been observed in hepatitis C (HCV)-infected, HIV-seropositive haemophiliacs. We studied the records of 176 haemophiliacs who were infected with HIV and/or HCV seen between 1980 and 1993. Thirty-two of 113 (28%) HIV-seropositive patients died during the study period. Ten of these patients died of liver failure, representing 31% of all mortality. An additional four HIV-seropositive patients who died of other causes had end-stage liver disease. Clinical liver failure occurred in 12% of the HIV-infected cohort. None of the HIV-seronegative, HCV-infected patients suffered from liver failure. Among HIV-infected patients, liver failure was associated with advanced age and decreased CD4 counts. Severe, sporadic ALT elevations were associated with liver failure; persistent transaminase elevations were associated with mortality. We conclude that HIV infection enhances progression of HCV infection to clinical liver failure, and that liver failure is a major cause of mortality in HIV-positive haemophiliacs.     

Improving the management of gastrointestinal bleeding in patients with cirrhosis

Gastrointestinal bleeding remains a major cause of mortality in patients with cirrhosis. The most common source of bleeding is from gastroesophageal varices but non-variceal bleeding from peptic ulcer disease also carries a significant risk in patients with liver disease. The prognosis is related to the severity of the underlying liver disease, and deaths often occur due to liver failure, infection or renal failure. Optimal management should therefore not only achieve haemostasis but address these complications as well. The management of gastrointestinal bleeding in patients with cirrhosis includes a range of medical, endoscopic and radiological interventions. This article updates the recent developments in this area and highlights topics where further research is still required.     

艾滋病合并HBV相关慢加急肝衰竭患者临床特征和预后分析

目的对艾滋病(AIDS)合并乙型肝炎病毒相关慢加急肝衰竭(HBV-ACLF)患者的临床诊疗数据和预后特征进行分析,提高对该病的认识。方法本研究纳入2012年6月至2020年10月在广州市第八人民医院住院的22例AIDS合并HBV-ACLF和39例HBV-ACLF患者,比较两组患者各临床指标和预后的差异,并对AIDS合并HBV-ACLF好转者与治疗失败者临床数据进行初步分析,总结其特点。结果(1)AIDS合并HBV-ACLF与HBV-ACLF组患者年龄和性别等一般资料无显著性差异(P>0.05),两组患者在发病前均未接受抗病毒治疗;血清丙氨酸氨基转移酶(Z=-2.478,P=0.013)在AIDS合并HBV-ACLF组显著低于HBV-ACLF组,HBV DNA(t=3.778,P<0.001)在AIDS合并HBV-ACLF组显著高于HBV-ACLF组,但两组患者治疗失败率无显著性差异(54.5%vs 46.1%,P=0.529),在12例AIDS合并HBV-ACLF治疗失败的患者中,2例(16.7%)患者因AIDS相关并发症(肺部感染)死亡,10例(83.3%)患者因肝衰竭及其相关并发症死亡。(2)对AIDS合并HBV-ACLF好转和治疗失败的患者临床数据进行初步分析的结果提示:好转组的年龄(Z=-2.574,P=0.009),MELD评分(t=-2.206,P=0.042),CD4⁺T淋巴细胞计数(Z=-2.374,P=0.017)显著低于治疗失败组,甲胎蛋白(Z=-2.317,P=0.020)在好转组显著高于治疗失败组。结论AIDS合并HBV-ALCF患者预后差,应予提前干预,其肝脏炎症反应程度和预后可能与患者的免疫状态有关。