终末期肝病的肝功能评估

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 Mayo TIPS模型 2001年 终末期肝病模型(Model for End-stage Liver Disease，MELD) Combined MELD 2007年 Lille Model,肝功能评估的发展历史,MELD,(Model for End-stage Liver Disease)(终末期肝病模型),MELD = 9.57 log e(creatine mg/dl) + 3.78 log e（积分） (bilirubin mg/dl) +11.20 log e (INR) + 6.4 3 (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: /int-med/gi/model/mayomodl-5-unos.htm to calculate MELD score directly,Liver Transpl,2003.9:19-20,Kiran M.Banbha,Curr opi org transp 2008,13:227-233,RELATIONSHIP BETWEEN MELD AND 3-MONTH MORTALITY IN HOSPITALIZED CIRRHOTIC PATIENTS,Adapted from Wiesner RH, McDiarmid SV, Kamath PS, et al :MELD and PELD: application of survival models to liver allocation. Liver Transpl 2001;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(Organ Procurement and Transplantation Network, OPTN)确定MELD为选择肝移植患者的新标准,MELD score No. of patients Perioperative mortality, n (%) 8 9,1-Year 3-Year 5-YearMELD score survival (%) survival (%) survival (%),Perioperative Mortality and long-term survival after Hepatic Resection for HCC,Journal Of Gastrointestinal Surgery 2005 Dec; Vol. 9 (9), pp. 1207-15,The perioperative mortality for patients with MELD 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 year survival (%),Transpl Int, 2006 Dec; Vol. 19 (12), pp. 988-94;,95.3 90.4 0.0001,94.9 84.7 0.0001,91.9 77.8 0.0001,88.1 72.1 0.0001,88.1 72.1 0.0001,Change in MELD score whilst on the transplant waiting list has a significant effect on survival post-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,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% per 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 cirrhosis,De Franchis R. J Hepatol 2005; 43:167176.,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, platelet count, gamma globulin level and HVPG were significant mortality predictors,DAmico G, J Hepatol 2006;44:217231.,MELD 联合血清钠水平(SNa),MELD-ASMELD-NaiMELD,MELD-AS,MELD-AS = MELD + 4.53 X 0,1*+ 4.46 X 0,1*,HEPATOLOGY. 2004 Oct; 40:802- 810,*If sodium 135mmol/L,=1;otherwise =0,*If persistent ascites,=1;otherwise =0,HEPATOLOGY. 2004 Oct; 40:802- 810,MELD-AS,CTP MELD MELD-ASALL MELDMELD21,0.789 0.83 0.874,0.696 0.687 0.790,0.586 0.773 0.758,Predictors of 180-day Cirrhotic Patient Mortality,MELD-AS may improve predictive accuracy,especially at lower MELD scores,Association between serum sodium levels and severity of ascites and complications of cirrhosis,血清钠 135mmol/L，,Hepatology 2006 Dec; 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 +1.0x(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 averting death,W.Ray Kim et al.N Eng J Med 2008;359:1018-26,W.Ray Kim et al.N Eng J Med 2008;359:1018-26,the 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 might have been prevented,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 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%) 115mol/L胆红素第0天、第7天分别指类固醇治疗开始时及治疗7天后所测得的胆红素水平可以利用/score.asp 网站计算Lille模型分值，在所对应的变量空格中填写相应数据即可得到,计算页面,拓展了“non-responder to corticosteroids”（对类固醇治疗无反应患者）定义范畴以往“non-responder to corticosteroids”是指无ECBL的患者拓展为Lille评分0.45的患者， Lille评分0.45的患者中有40%对类固醇治疗无反应Mathurin P, Louvet A, Dharancy S.Treatment of severe forms of alcoholic hepatitis: where are we going?J Gastroenterol Hepatol. 2008;23 Suppl 1:S60-62.,Lille 模型临床应用,Lille 模型临床应用,预测ALD患者类固醇治疗后发生感染的风险Lille评