终末期肝病的肝功能评估[1].ppt

肝硬化患者肝脏储备功能的研究进展 上海交通大学医学院附属仁济医院上海市消化疾病研究所 邱德凯 1964年Child Turcotte肝功能分级1973年Child Turcott Pugh CTP 1997年UNOS成人 18岁 肝病严重程度分级2000年MayoTIPS模型2001年终末期肝病模型 ModelforEnd stageLiverDisease MELD CombinedMELD2007年LilleModel 肝功能评估的发展历史 MELD ModelforEnd stageLiverDisease 终末期肝病模型 MELD 9 57 loge creatinemg dl 3 78 loge 积分 bilirubinmg dl 11 20 loge INR 6 43 肝硬化病因 胆汁性或酒精性0 其余为1 6 40 若MELD积分相同则 MELD 30d内积分的差值 0表明疾病在进展 0表明疾病处于相对平稳期或在好转 see http www mayo edu int med gi model mayomodl 5 unos htmtocalculateMELDscoredirectly LiverTranspl 2003 9 19 20 KiranM Banbha Curropiorgtransp2008 13 227 233 RELATIONSHIPBETWEENMELDAND3 MONTHMORTALITYINHOSPITALIZEDCIRRHOTICPATIENTS AdaptedfromWiesnerRH McDiarmidSV KamathPS etal MELDandPELD applicationofsurvivalmodelstoliverallocation LiverTranspl2001 7 567 580 2002年2月27日 美国器官共享网 全美器官获取和移植网 OrganProcurementandTransplantationNetwork OPTN 确定MELD为选择肝移植患者的新标准 MELDscoreNo ofpatientsPerioperativemortality n 8 9 1 Year3 Year5 YearMELDscoresurvival survival survival PerioperativeMortalityandlong termsurvivalafterHepaticResectionforHCC JournalOfGastrointestinalSurgery2005Dec Vol 9 9 pp 1207 15 TheperioperativemortalityforpatientswithMELDscore 9wassignificantlygreaterthanthatforpatientswithMELDscore 8 0 01 Thelong termsurvivalforpatientswithMELDscore 9wassignificantlyshorterthanthatforpatientswithMELDscore 8 0 01 370 0 4513 29 8896351 9463423 Outcomepost transplantdependenton MELDbetweenlistingandtransplant MELD 1 MELD 1P value90daysurvival 180daysurvival 1yearsurvival 2yearsurvival 3yearsurvival TransplInt 2006Dec Vol 19 12 pp 988 94 95 390 40 0001 94 984 70 0001 91 977 80 0001 88 172 10 0001 88 172 10 0001 ChangeinMELDscorewhilstonthetransplantwaitinglisthasasignificanteffectonsurvivalpost transplant MELD的局限性 没有包括任何临床症状的判断 也没有考虑到患者的生活质量 对于合并有严重的门脉高压 顽固性腹水以及肝性脑病的病人 在实行器官分配原则时 应当增加除MELD之外的其它附加条件 Fourclinicalstagesofcirrhosis stage1 patientswithoutvaricesorascites mortalityisabout1 peryear Stage2 patientswithvaricesbutwithoutascitesorbleeding mortalityrateofabout4 peryear Stage3 patientshaveasciteswithorwithoutesophagealvaricesthathaveneverbled mortalityratewhileremaininginthisstageis20 peryear Stage4 withportalhypertensiveGIbleedingwithorwithoutascites 1 yearmortalityrateof57 compensatedcirrhosis decompensatedcirrhosis DeFranchisR JHepatol2005 43 167 176 HVPG patientswithanHVPG 10mmHghada90 probabilityofnotdevelopingclinicaldecompensationduringafollow upperiodofupto4yearsIncompensatedcirrhosis markersofportalhypertensionsuchasvarices splenomegaly plateletcount gammaglobulinlevelandHVPGweresignificantmortalitypredictors D AmicoG JHepatol2006 44 217 231 MELD联合血清钠水平 SNa MELD ASMELD NaiMELD MELD AS MELD AS MELD 4 53X 0 1 4 46X 0 1 HEPATOLOGY 2004Oct 40 802 810 Ifsodium 135mmol L 1 otherwise 0 Ifpersistentascites 1 otherwise 0 HEPATOLOGY 2004Oct 40 802 810 MELD AS CTPMELDMELD ASALLMELDMELD21 0 7890 830 874 0 6960 6870 790 0 5860 7730 758 Predictorsof180 dayCirrhoticPatientMortality MELD ASmayimprovepredictiveaccuracy especiallyatlowerMELDscores Associationbetweenserumsodiumlevelsandseverityofascitesandcomplicationsofcirrhosis 血清钠 135mmol L Hepatology2006Dec Vol 44 6 pp 1535 42 发生腹水的概率要比血钠水平正常的患者高 血清钠 130mmol L 更容易出现肝性脑病 自发性细菌性腹膜炎 肝肾综合征 MELD Na MELD Na MELD 1 0 x 140 Na 0 025 MELD 140 Na UseoftheMEL DNascoremayreducemortalityamongpatientsonthewaitinglist ThedifferencebetweentheMELDscoreandtheMELD Nascorewasoftenlargeenoughtomakearealdifferenceintheprobabilityofreceivingalivertransplantandavertingdeath W RayKimetal NEngJMed2008 359 1018 26 W RayKimetal NEngJMed2008 359 1018 26 theexpectednumberoftransplantations 67 58 4 18 5 43 70 4 58 4 32Thus 7 ofdeaths 32of477 thatoccurredwithin3monthsafterregistrationonthewaitinglistmighthavebeenprevented PrevalenceofAscites SeverityofLiverFailure RenalFunction andMortalityAccordingtoHyponatremiaStatusinPatientsNotTransplantedWithin3Months NohyponatremiaHyponatremia Value n 160 n 34 pSerumsodium mEq L 138 3127 4 0 001Clinicalascites66 41 34 100 0 001Totalbilirbin mg dL 5 3 5 911 1 9 1 0 001INR1 5 0 51 9 1 1 0 001MELDscore15 4 5 221 1 7 9 0 001Serumcreatinine mg dL 0 8 0 30 8 0 40 28Elevatedserumcreatinine5 3 3 9 0 143 monthmortality7 4 12 35 0 001 Hyponatremiawasdefinedasserumsodium 130mEq L LiverTransplantation Vol11 No3 2005 pp336 343 iMELD iMELDscore MELD 0 3 年龄 0 7 血清钠 100 LiverTranspl 2007Aug Vol 13 8 pp 1174 80 iMELD Mortalityin451patientswithcirrhosislistedforlivertransplantation iMELDMELD3 month6 month12 month 0 76 0 70 0 79 0 71 0 78 0 69 iMELDimprovesthepredictiveaccuracyoftimetodeath LiverTranspl2007Aug Vol 13 8 pp 1174 80 ESTIMATINGPROGNOSISINPATIENTSWITHPRIMARYBILIARYCIRRHOSIS PBC MAYOPBCRISKSCORER 0 871log serumbilirubininmg dL 2 53xlog albumining dL 0 039 ageinyears 2 38xlog prothrombintimeinseconds 0 859 ifedemapresent RiskscoreistranslatedintoasurvivalfunctiontoestimatesurvivalfortheindividualpatientwithPBC Othermodelshaveemphasizedvaricealbleedingasanimportantadditionalclinicalprognosticator PROGNOSTICINDEXFORSURVIVALAFTERLIVERTRANSPLANTATIONINPATIENTSWITHPBCPI 0 60 xlog serumbilirubininmg dL 0 82xlog serumureainmmol L 1 14 transplantationbefore1985 0 92 diuretic responsiveascites 1 70RiskScore4 MonthSurvival9 957 酒精性肝病严重程度评估方法 Maddrey判别函数DF 4 6 PT延长 秒 TB mg dl DF有助于判断AH患者的预后 DF大于32者8周内死亡率高达50 以上 DF大于32者又称重症AHPhillipsMetal Antioxidantsversuscorticosteroidsinthetreatmentofseverealcoholichepatitis arandomizedclinicaltrial JHepatol 2006 44 784 790 酒精性肝病严重程度评估方法 TB水平早期变化模式 ECBL 定义 激素治疗第7天的TB水平低于第1天临床意义 95 ECBL患者在治疗期间可获得持续的肝功能改善 6个月时 ECBL患者生存率为82 8 显著高于无ECBL患者的23 多因素分析表明 ECBL 年龄 DF和肌酐都是独立的预测参数 而ECBL预测价值最大MathurinPetal Earlychangeinbilirubinlevels ECBL isanimportantprognosticfactorinseverebiopsy provenalcoholichepatitis AH treatedbyprednisolone Hepatology 2003 88 1363 1369 Lille模型 Lille模型于2007年由法国CHRULille医院肝病科联合其他四个中心首次提出计算公式 Lille积分 3 19 0 101 年龄 years 0 147 白蛋白 g L 0 0165 胆红素 day7 mol L 0 206 有肾功能不全取1 无肾功能不全取0 0 0065 胆红素 day0 mol L 0 0