急性肝衰竭的治疗进展

急性肝衰竭(acute liver failure,ALF)是指原来无肝脏疾病(主要指肝硬化)的患者,由于肝细胞大量坏死或功能丧失发生急性严重肝功能不全,导致以肝性脑病(hepatic encephalopathy,HE)和凝血功能障碍为主要特征的临床综合征。此综合征病情严重、临床症状复杂、病死率高。患者的生存率与病因、脑病程度及多器官衰竭密切有关,主要的死因是感染和进行性脑水肿。随着肝移植的开展,短期生存率超过境5%。尽管如此,急性肝衰竭的治疗仍面临一些挑战。1重症监护与一般治疗对于确诊的ALF的患者,尽早转入重症监护病房(ICU)中密切观察生命体征,严格消…     

暴发性肝衰竭的治疗

暴发性肝衰竭是由于肝细胞大块坏死或急剧弥漫性肝细胞变性,肝功能严重损害造成的临床综合征。原因复杂,预后恶劣,治疗上尚无特效方法,是临床医师经常遇到的棘手问题之一,值得深入探讨。近几年来对暴发性肝衰竭的治疗未取得突破性进展,但随着对暴发性肝衰竭发病机制了解的深入,治疗方法上有许多改进,使病死率由60～90％降至40～53.8％;亚急性重症肝炎由78.1％降低到36～36.58％。 (一)重视监护及支持疗法凡暴发性肝衰竭均应放入监护病室,集中观察,按预定方案由专门医护小组护理、治疗。患者严格卧床,给予适当饮食,必要时输注10％葡萄糖、维生素、氯化钾、保证每天热量5026～6702KJ(1200～1600千卡)。对危重病人     

对重型肝炎肝衰竭诊疗现状的思考

重型肝炎肝衰竭是威胁患者生命的严重疾病，病死率极高。尽管随着肝移植、人工肝和内科治疗的进展，重型肝炎肝衰竭的治疗效果显著提高，但是由于其相对少见、进展迅速、难以开展临床对照研究等原因，与其他重症疾病相比，一直缺乏完善、系统、规范的治疗方案。特别是由于国内外重型肝炎肝衰竭在病因、定义、预后、治疗等方面的巨大差异，不能照搬国外的经验，因此，国内学者在积极借鉴国外同行经验的同时，应积极开展科学的临床和基础研究，建立一套适合我国重型肝炎肝衰竭特点的理论和实践体系，提高诊断和治疗水平。     

肝衰竭的治疗现状

肝衰竭是多种因素引起的严重肝损伤。对目前治疗肝衰竭采用的方法进行了总结归纳,公认的治疗方法有重症监护与支持治疗、针对病因治疗、调节免疫治疗、防治各种并发症、人工肝支持治疗以及肝移植等。认为肝衰竭的治疗更应强调"内科-人工肝-肝移植"的综合治疗模式,临床工作中坚持早诊断、早治疗,针对不同病因采取相应的综合治疗措施,积极防治各种并发症,同时还应建立多学科团队,制订个性化的诊疗方案,从而降低病死率,改善患者的临床结局。     

生物人工肝--理想的体外人工肝支持系统

临床上,各种原因所致肝衰竭的治疗问题,一直是最为棘手、最需要尽快解决的问题。很少有比肝功能衰竭更具破坏性的情况,因为肝脏内富含600多种生物酶,具有复杂的代谢、生物合成、生物转化、解毒及排泄等功能。肝衰竭将造成严重的代谢紊乱和毒物聚积,并常导致肝外其他脏器功能衰竭,形成多脏器功能衰竭综合征,病死率极高。尽管重症监护措施及对症支持疗法在不断进步,但暴发性肝衰竭(FHF)的病死率仍居高不下,维持在80％左右,而FHF中Ⅳ期肝性脑病者病死率则高达90％～95％。     

肝再生增强因子在肝脏中的作用

肝再生增强因子（ALR）除了促进肝再生，保护肝损伤之外，可能在肝脏的器官形成和发育中也发挥着重要作用。介绍了ALR在肝脏中的生物学功能和机制研究的最新进展，并归纳总结了ALR在肝脏疾病的诊断和治疗中的应用。指出ALR可能通过线粒体途径调控肝细胞的凋亡，从而参与肝脏的修复和再生。未来ALR可能作为肝衰竭患者肝再生及预后评估的候选分子，并有望成为临床治疗严重肝病和肝衰竭的有效药物。     

干细胞治疗肝衰竭的现状和进展

<正>肝衰竭是多种因素(如病毒感染、毒性药物、代谢疾病、酒精等)引起的严重肝脏损害,导致其合成、解毒、排泄和生物转化等功能发生严重障碍或失代偿,出现以凝血功能障碍、黄疸、肝性脑病、腹水等为主要表现的一组临床症候群[1]。肝移植是目前唯一有效治愈肝衰竭的方法,但由于供肝短缺,费用昂贵,无法满足众多肝衰竭患者的治疗需求,这就要求肝脏病学界探索其他可行的替代治疗手段。干细胞已被证实具有强大的分     

生物人工肝在肝衰竭治疗中的应用

重型肝炎及其引起的肝衰竭病死率极高,迄今仍缺乏特效的治疗方法.目前公认的最有效的治疗方法是肝移植,但由于供肝短缺,远远不能满足临床需求.例如在美国,14%需要紧急肝移植的患者在等待供肝过程中死亡.如果在肝衰竭的严重阶段通过人工的或者辅助的手段代替肝脏的主要功能,则患者将有更多机会获得供肝或者避免肝移植.各种非生物型人工肝,如血液灌流、血浆置换等由于其不能代替肝脏的合成和代谢功能而疗效有限.     

暴发性肝衰竭的临床治疗研究新进展

暴发性肝衰竭是由于肝细胞大量坏死而出现以肝功能严重受损为特征的综合征。暴发性肝衰竭的病死率高达 80 %～90 %,这种不良后果反映了肝脏受损严重而再生不足 ,以及由于全身性炎性细胞因子表达过高所致的多器官功能衰竭。临床上 ,患者发展为暴发性肝衰竭的信号包括神经功能紊乱 (肝性脑病 )、肾功能衰竭和心肺衰竭 ,患者通常死于继全身炎症反应综合征 (ｓｙｓｔｅｍｉｃｉｎｆｌａｍｍａｔｏｒｙｒｅｓｐｏｎｓｅｓｙｎｄｒｏｍｅ ,ＳＩＲＳ)后的严重感染[1] 。肝炎病毒、药物和休克均可引起暴发性肝衰竭 ,但大部分暴发性肝衰竭由病毒感染…     

超敏C反应蛋白在急性肝衰竭患者诊断和预后的临床价值

正肝衰竭是由于多种致病因素引起肝脏功能严重损害,肝脏的合成、解毒、排泄和代谢等生理功能发生失代偿或严重障碍,出现酶胆异常、凝血机制功能障碍、肝性脑病和腹水等一系列表现的临床综合征[1]。肝衰竭按照病理组织学特征和病情发展速度,一般分为急性肝衰竭、亚急性肝衰竭、慢加急性肝衰竭     

Manejo de la insuficiencia hepática aguda grave. Documento de posicionamiento de la Societat Catalana de Digestologia

Acute liver failure is an uncommon and severe disease characterised by a rapid onset of severe hepatocellular failure in individuals without previous liver disease. Initial management of this entity determines the outcome of the patient. Initial contact with the acute liver failure patients usually occurs in the emergency department, digestology clinic or, in more severe cases, intensive care units. The management of acute liver failure patients in all these cases must be multidisciplinary, involving surgeons and hepatologists who are experts in this condition, meaning those from hospitals with active liver transplant programmes.This article reviews the current body of evidence concerning the medical management of acute liver failure patients, from the suspected diagnosis and initial management to intensive medical treatment, including the need for an emergency liver transplantation. Moreover, we also review the use of artificial liver support systems in this setting.     

Intensive management of hepatic failure

A substantial number of patients with liver failure are admitted to the intensive care unit; thus a thorough understanding of the prevention and treatment of complications in such patients is imperative. The management of liver failure is demanding and often involves the combined efforts of many specialists. Critically ill patients with hepatic failure encompass a broad spectrum of disease, ranging from acute liver failure in a patient with no prior history of liver disease, to acute or chronic liver failure. The initial assessment and management of acute liver failure are reviewed with an emphasis on the prevention and treatment of brain edema in the pretransplant setting. The current treatment of complications resulting from decompensated chronic liver disease such as portal hypertensive bleeding; infection, renal failure, and hepatic encephalopathy are then discussed.     

Akutes Leberversagen

Acute liver failure is a multisystem disease with predominantly sudden and severe hepatic injury and hepatic encephalopathy caused by apoptotic or necrotic hepatocyte damage. The clinical challenge in patients with acute liver failure is to promptly identify those with poor prognosis and refer them for emergency liver transplantation. This review article highlights the main aspects of decision making in the setting of acute liver failure, summarizes new aspects of its critical care management and gives an overview of sclerosing cholangitis in the critically ill patient, an under-recognized disease entity that can progress to acute liver failure.     

Acute liver failure. How much diagnostic work-up and therapy does my patient need?

Acute liver failure is a multisystem disease with predominantly sudden and severe hepatic injury and hepatic encephalopathy caused by apoptotic or necrotic hepatocyte damage. The clinical challenge in patients with acute liver failure is to promptly identify those with poor prognosis and refer them for emergency liver transplantation. This review article highlights the main aspects of decision making in the setting of acute liver failure, summarizes new aspects of its critical care management and gives an overview of sclerosing cholangitis in the critically ill patient, an under-recognized disease entity that can progress to acute liver failure.     

高度依赖病房及其在重症肝病患者临床管理中的应用

[摘要]高度依赖病房（high dependency unit, HDU）可为单器官衰竭（呼吸衰竭除外）患者提供介于普通病房与重症监护病房之间的中等水平的护理。重症肝病（severe liver disease, SLD）患者肝功能严重障碍，多表现出急性或慢性单器官衰竭。HDU可满足SLD患者的监护需求，但目前国内仅有少数医院开设HDU。本文通过介绍HDU的概念、类型、作用以及SLD HDU建设与应用的研究进展，表明HDU在SLD患者临床管理中的应用将有助于医疗团队为患者实施更安全高效的救治，同时为推广建设HDU提供了理论及实践依据。     

A woman presenting with an unusual cause of fulminant liver failure and sepsis

We present the case of a 61-year-old woman who presented with acutely worsening right upper quadrant pain and was found to be in acute liver failure with Klebsiella pneumoniae bacteremia. Despite aggressive intensive care management, the patient ultimately died of refractory shock attributed to sepsis and fulminant liver failure. On autopsy, she was found unexpectedly to have diffuse intrahepatic cholangiocarcinoma with metastases to regional lymph nodes and intravascular spread to the lungs. The case highlights a rare instance where intrahepatic cholangiocarcinoma presents with acute liver failure and discusses key intensive care management principles of this clinical syndrome.     

Die Überwachung der Leberfunktionen in der Intensivmedizin

The relevance of liver dysfunction in the management of critically ill patients is increasingly being recognized. It has been found to affect mortality of patients with septic organ failure in several studies. The increasing prevalence of chronic liver disease among intensive care patients adds importance to the issue of monitoring the various aspects of liver function. An array of liver function tests as part of blood biochemistry testing has long been established. In the context of critical care and chronic liver disease, however, they must be interpreted cautiously. In addition, several dynamic tests of liver function have been developed. Relatively best explored are tests based on the hepatic elimination of indocyanine-green (ICG). Commercially available systems analyzing the plasma disappearance rate of ICG (ICG-PDR) are being marketed but these parameters also are difficult to interpret in the intensive care setting and especially in patients with chronic liver disease. ICG-PDR correlates with mortality in patients with septic organ dysfunction but studies investigating the outcome-oriented results of therapeutic interventions directed by these parameters have not been published. The possible relevance to intensive care management of several other dynamic tests of liver function, as well as interventional and ultrasonografic methods to address liver perfusion, are discussed in the article. As yet, there is no single method to monitor the various aspects of liver function and no method whose clinical value has been proved. Clinicians therefore have to mostly rely on clinical judgement aided by a reasonable selection among existing monitoring tools.     

结肠途径治疗机辅助治疗肝衰竭的护理

目的探讨IMS—100A结肠途径治疗机辅助治疗肝衰竭的临床护理。方法在采用IMS—100A结肠途径治疗机治疗24例肝衰竭患者过程中,严格按照操作规程,准确到位,及时处理不良反应。结果对24例肝衰竭患者在结肠途径治疗中的护理保证了结肠途径治疗肝衰竭的临床疗效,减少了肝性脑病、腹水的发生。结论结肠途径治疗机的治疗方法可减少肠内毒素的生成和吸收,加速毒素排除,纠正电解质紊乱,达到辅助治疗肝衰竭的作用。     

Intensive care management of acute liver failure

The care of patients with acute liver failure (ALF) presents unique clinical challenges to the practicing physician. It combines the management of rapidly progressive, severe multiple organ failure, unpredictable and often devastating complications, and a need for urgent decision-making in the application of emergency liver transplantation. However, outcomes for patients with this condition have shown progressive improvement over the last four decades. In this article, practical clinical approaches to the care of critically ill patients with ALF are discussed, taking an organ systems-based perspective and discussing the underlying pathophysiological processes and major areas of uncertainty as to what constitutes best practice.     

Advances in the management of acute liver failure

Acute liver failure(ALF)is an uncommon but dramatic clinical syndrome characterized by hepatic encephalopathy and a bleeding tendency due to abrupt loss of liver function caused by massive or submassive liver necrosis in a patient with a previously healthy liver.The causes of ALF encompass a wide variety of toxic,viral,metabolic,vascular and autoimmune insults to the liver,and identifying the correct cause can be difficult or even impossible.Many patients with ALF develop a cascade of serious complications involving almost every organ system,and death is mostly due to multi-organ failure,hemorrhage,infection,and intracranial hypertension.Fortunately,the outcome of ALF has been improved in the last 3 decades through the specific treatment for the disease of certain etiology,and the advanced intensive care management.For most severely affected patients who fail to recover after treatment,rapid evaluation for transfer to a transplantation center and consideration for liver transplantation is mandatory so that transplantation can be applied before contraindications develop.This review focuses on the recent advances in the understanding of various contributing etiologies,the administration of etiology-specific treatment to alleviate the liver injury,and the management of complications(e.g.,encephalopathy,coagulopathy,cardiovascular instability,respiratory failure,renal failure,sepsis and metabolic disturbance)in patients with ALF.Assessment of the need for liver transplantation is also presented.