肝病肝功能評估

1、關于肝病的肝功能評估第一張，PPT共三十頁，創(chuàng)作于2022年6月1964年 Child-Turcotte 肝功能分級 1973年 Child-Turcott-Pugh (CTP)1997年 UNOS 成人(18歲)肝病嚴重程度分級 2000年 Mayo TIPS模型 2001年 終末期肝病模型(Model for End-stage Liver Disease，MELD) Combined MELD 2007年 Lille Model 肝功能評估的發(fā)展歷史第二張，PPT共三十頁，創(chuàng)作于2022年6月Child-Turcotte-Pugh肝功能分級指標 評分標準123腹水無少量中等量以上或難治性

2、腹水血清膽紅素(umol/L) 51血清白蛋白(g/l) 352835 28凝血酶原時間(較正常延長秒數(shù))or(INR)*13（正常值范圍內(nèi)）1.746（延長 6 （延長 2秒） 2.3肝性腦病無1-2級3-4級 *INR, international normalised ratio.估 計 生 存 率 (%)總積分分組一年二年0表明疾病在進展； 0表明疾病處于相對平穩(wěn)期或在好轉(zhuǎn)。 see: /int-med/gi/model/mayomodl-5-unos.htm to calculate MELD score directlyLiver Transpl,2003.9:19-20 Kira

3、n M.Banbha,Curr opi org transp 2008,13:227-233第四張，PPT共三十頁，創(chuàng)作于2022年6月RELATIONSHIP BETWEEN MELD AND 3-MONTH MORTALITY IN HOSPITALIZED CIRRHOTIC PATIENTS MELDMORTALITY (%; NUMBER/TOTAL) 94 (6/148) 10-1927 (28/103) 20-2976 (16/21) 30-3983 (5/6) 40100 (4/4)Adapted from Wiesner RH, McDiarmid SV, Kamath PS

4、, et al :MELD and PELD: application of survival models to liver allocation. Liver Transpl 2001;7:567-580第五張，PPT共三十頁，創(chuàng)作于2022年6月第六張，PPT共三十頁，創(chuàng)作于2022年6月2002年2月27日：美國器官共享網(wǎng)/全美器官獲取和移植網(wǎng)(Organ Procurement and Transplantation Network, OPTN)確定MELD為選擇肝移植患者的新標準 第七張，PPT共三十頁，創(chuàng)作于2022年6月MELD score No. of patients Pe

5、rioperative mortality, n (%) 8 9 1-Year 3-Year 5-YearMELD score survival (%) survival (%) survival (%) Perioperative Mortality and long-term survival after Hepatic Resection for HCCJournal Of Gastrointestinal Surgery 2005 Dec; Vol. 9 (9), pp. 1207-15The perioperative mortality for patients with MELD

6、 score 9 was significantly greater than that for patients with MELD score 8 (0.01).The long-term survival for patients with MELD score 9 was significantly shorter than that for patients with MELD score 8 ( +1 P-value90 day survival (%) 180 day survival (%) 1 year survival (%) 2 year survival (%) 3 y

7、ear survival (%) Transpl Int, 2006 Dec; Vol. 19 (12), pp. 988-94; 95.3 90.4 0.000194.9 84.7 0.000191.9 77.8 0.000188.1 72.1 0.000188.1 72.1 0.0001Change in MELD score whilst on the transplant waiting list has a significant effect on survival post-transplant第九張，PPT共三十頁，創(chuàng)作于2022年6月MELD的局限性沒有包括任何臨床癥狀的判斷

8、，也沒有考慮到患者的生活質(zhì)量 對于合并有嚴重的門脈高壓、頑固性腹水以及肝性腦病的病人，在實行器官分配原則時，應當增加除MELD之外的其它附加條件 第十張，PPT共三十頁，創(chuàng)作于2022年6月Four clinical stages of cirrhosis stage 1 :patients without varices or ascites (mortality is about 1% per year)Stage 2 : patients with varices but without ascites or bleeding (mortality rate of about 4% pe

9、r year )Stage 3 :patients have ascites with or without esophageal varices that have never bled (mortality rate while remaining in this stage is 20% per year )Stage 4 :with portal hypertensive GI bleeding with or without ascites (1-year mortality rate of 57% )compensated cirrhosis decompensated cirrh

10、osis De Franchis R. J Hepatol 2005; 43:167176.第十一張，PPT共三十頁，創(chuàng)作于2022年6月HVPG patients with an HVPG 10mmHg had a 90% probability of not developing clinical decompensation during a follow-up period of up to 4 years In compensated cirrhosis, markers of portal hypertension such as varices, splenomegaly, pl

11、atelet count, gamma globulin level and HVPG were significant mortality predictors DAmico G, J Hepatol 2006;44:217231.第十二張，PPT共三十頁，創(chuàng)作于2022年6月MELD 聯(lián)合血清鈉水平(SNa)MELD-ASMELD-NaiMELD第十三張，PPT共三十頁，創(chuàng)作于2022年6月MELD-AS MELD-AS = MELD + 4.53 X 0,1*+ 4.46 X 0,1* HEPATOLOGY. 2004 Oct; 40:802- 810*If sodium 135mmol

12、/L,=1;otherwise =0 *If persistent ascites,=1;otherwise =0第十四張，PPT共三十頁，創(chuàng)作于2022年6月HEPATOLOGY. 2004 Oct; 40:802- 810MELD-AS CTP MELD MELD-ASALL MELDMELD21 0.789 0.83 0.874 0.696 0.687 0.790 0.586 0.773 0.758Predictors of 180-day Cirrhotic Patient MortalityMELD-AS may improve predictive accuracy,especia

13、lly at lower MELD scores第十五張，PPT共三十頁，創(chuàng)作于2022年6月Association between serum sodium levels and severity of ascites and complications of cirrhosis血清鈉 135mmol/L， Hepatology 2006 Dec; Vol. 44 (6), pp. 1535-42. 發(fā)生腹水的概率要比血鈉水平正常的患者高；血清鈉 130mmol/L， 更容易出現(xiàn)肝性腦病、自發(fā)性細菌性腹膜炎、 肝腎綜合征。 第十六張，PPT共三十頁，創(chuàng)作于2022年6月MELD-NaMELD

14、-Na = MELD +1.0 x(140- Na) 0.025 MELD (140 Na) .Use of the MEL-DNa score may reduce mortality among patients on the waiting list.The difference between the MELD score and the MELD-Na score was often large enough to make a real difference in the probability of receiving a liver transplant and avertin

15、g deathW.Ray Kim et al.N Eng J Med 2008;359:1018-26第十七張，PPT共三十頁，創(chuàng)作于2022年6月W.Ray Kim et al.N Eng J Med 2008;359:1018-26the expected number of transplantations : 67 (58.4% 18.5%)+ 43 (70.4% 58.4%)=32 Thus, 7% of deaths (32 of 477) that occurred within 3 months after registration on the waiting list mi

16、ght have been prevented第十八張，PPT共三十頁，創(chuàng)作于2022年6月Prevalence of Ascites, Severity of Liver Failure, Renal Function, and Mortality According to HyponatremiaStatus in Patients Not Transplanted Within 3 Months No hyponatremia Hyponatremia Value (n=160) (n=34) pSerum sodium (mEq/L) 138 3 127 4 0.001Clinical

17、 ascites 66 (41%) 34 (100%) 0.001Total bilirbin (mg/dL) 5.3 5.9 11.1 9.1 0.001INR 1.5 0.5 1.9 1.1 0.001MELD score 15.4 5.2 21.1 7.9 0.001Serum creatinine (mg/dL) 0.8 0.3 0.8 0.4 0.28Elevated serum creatinine 5 (3%) 3 (9%) 0.143-month mortality 7 (4%) 12 (35%) 0.001 Hyponatremia was defined as serum

18、sodium 130 mEq/LLiver Transplantation,Vol 11,No3 ,2005: pp336-343第十九張，PPT共三十頁，創(chuàng)作于2022年6月iMELDiMELD score=MELD + (0.3年齡) - (0.7血清鈉) + 100 Liver Transpl 2007 Aug; Vol. 13 (8), pp. 1174-80第二十張，PPT共三十頁，創(chuàng)作于2022年6月iMELDMortality in 451 patients with cirrhosis listed for liver transplantation. iMELD MELD3-

19、month6-month12-month 0.76 0.70 0.79 0.71 0.78 0.69 iMELD improves the predictive accuracy of time to death Liver Transpl 2007 Aug; Vol. 13 (8), pp. 1174-80第二十一張，PPT共三十頁，創(chuàng)作于2022年6月ESTIMATING PROGNOSIS IN PATIENTS WITH PRIMARY BILIARY CIRRHOSIS (PBC)MAYO PBC RISK SCORER = 0.871 log(serum bilirubin in

20、mg/dL) 2.53 x log (albumin in g/dL) + 0.039 + (age in years) + 2.38 x log(prothrombin time in seconds) + 0.859 (if edema present) Risk score is translated into a survival function to estimate survival for the individual patient with PBC. Other models have emphasized variceal bleeding as an important

21、 additional clinical prognosticator.PROGNOSTIC INDEX FOR SURVIVAL AFTER LIVER TRANSPLANTATION IN PATIENTS WITH PBCPI = 0.60 x log (serum bilirubin in mg/dL) + 0.82 x log (serum urea in mmol/L) + 1.14 + (transplantation before 1985) 0.92 (diuretic-responsive ascites) + 1.70 Risk Score 4-Month Surviva

22、l 9.9 57%第二十二張，PPT共三十頁，創(chuàng)作于2022年6月酒精性肝病嚴重程度評估方法Maddrey判別函數(shù)DF=4.6PT延長（秒）TB（mgdl），DF有助于判斷AH患者的預后，DF大于32者8周內(nèi)死亡率高達50%以上， DF大于32者又稱重癥AHPhillips M et al. Antioxidants versus corticosteroids in the treatment of severe alcoholic hepatitis a randomized clinical trial. J Hepatol, 2006; 44:784-790. 第二十三張，PPT共三十

23、頁，創(chuàng)作于2022年6月酒精性肝病嚴重程度評估方法TB水平早期變化模式（ECBL）定義：激素治療第7天的TB水平低于第1天臨床意義：95ECBL患者在治療期間可獲得持續(xù)的肝功能改善。6個月時， ECBL患者生存率為82.8，顯著高于無ECBL患者的23。多因素分析表明，ECBL、年齡、DF和肌酐都是獨立的預測參數(shù)，而ECBL預測價值最大 Mathurin P et al. Early change in bilirubin levels (ECBL) is an important prognostic factor in severe biopsy-proven alcoholic hepa

24、titis (AH) treated by prednisolone. Hepatology, 2003; 88:1363-1369.第二十四張，PPT共三十頁，創(chuàng)作于2022年6月Lille 模型Lille模型于2007年由法國CHRU Lille醫(yī)院肝病科聯(lián)合其他四個中心首次提出 計算公式：Lille 積分= 3.190.101 * 年齡(years) + 0.147 * 白蛋白 (g/L)0.0165 *膽紅素(day 7) (mol/L)0.206 * (有腎功能不全取1，無腎功能不全取0) 0.0065 *膽紅素 (day 0)（mol/L)0.0096 * 凝血酶原時間 (seconds).說明：腎功能不全評價標準：肌酐是否115mol/L膽紅素第0天、第7天分別指類固醇治療開始時及治療7天后所測得的膽紅素水平可以利用/score