肝病凝血改变课件

肝病患者的凝血改变肝病患者的凝血改变1置管11天,拔管4天后置管11天,拔管4天后2慢性肝病患者血栓栓塞发生情况1979-2006E≌5DVTFigurePom1979-2006ofpuImonaryembolism(PE),decthrombosis(DVT),andvenousthromboembolism(VTE)inhospitalizedadultpaticntswithalcoholicliverdiscaseandnonalcoholicliverdisease(alldifte慢性肝病患者静脉血栓的流行情况低于其他疾病TheAmericanJournalofMedicine(2011)124,64-68慢性肝病患者血栓栓塞发生情况3门静脉血栓门静脉血栓4门静脉血栓流行情况3796例尸检患者在主要引起门静脉血栓的病因中PVT的流行情况n=254Patientcategoryn(%)ofn(%)withinAge(yr)PVTpatientsriskcategoryMedianMean(95%C)withoutprimaryhepaticcancerPrimaryhepatobiliarycancer59(23)721(694-748)hepaticcarcinomaextrahepaticbiliary/gallbladdercarcinomaSecondarymalignancyofthehepatobiliaryregion111(4)690(667-71.2frompancreaticcarcinomagastriccarcinomacolorectalcarcinomalungcancermalignantlymphomamammaryadenocarcinomaotherprimaryMyeloproliferativedisorders654(442-86.6)Majorabdominalinfection/inflammation1.9(665-773Nocauseidentified708(659-757AllpatientswithPVT254(100)699(683-71.4门静脉血栓流行情况5肝硬化和肝癌患者发生门静脉血栓的风险较高存在门静脉风险疾病的发生PVT的流行和发生的相对风险(ods比值)N=23796Pacientcategoryn(%)PT(%)O.R.(95%C.)O.R.(95%CL)withoutprimaryhepaticca46{45)0001Primaryhepatobiliarycancer698②29)5985)10.880-165)<000withcirrhosis26(143)171(11-264)<00028(.3-56)00458(32-106)<00extrahepaticbiliarygallbladdercarcinoma21(67)72(45-114)<0.00Secondaryhepaticmalignancyfromalltumours3446(145)13033)49(38-62frompancreaticcarcinoma36(1.5)13.9096-202)m52(34-782<003gastriccarcunoma31618⑤57)59(369719(12-32)30.0192colorectalcarcinoma1320)5(03-10)3Myeloproliferativedisorders23101.0)30)30(14-63)0012Allpatients237960100)254(.0)WorldGastroenter肝硬化和肝癌患者发生门静脉血栓的风险较高6肝硬化患者出血发生情况肝硬化(25%35%)门脉高压凝血功能障碍食管静脉曲张(90%)因素较小肝硬化患者出血发生情况7正常的凝血酶生成和抑制反应Thrombin-TFPI(IXa)PL(VIlla)ThrombinVIllPSAPC<Thrombin-TMPCTFV|→(XaThrombin-(AX川arbn9n》FFibrinx-link正常的凝血酶生成和抑制反应8肝硬化患者凝血功能改变VWF和Ⅷ因子水平↑tPA、NO、和前列环素水平↑促进和抑制凝血因子水平↓纤维蛋白原和纤溶抑制剂水平↓ADAMTS水平↓血小板数量减少和异常纤维蛋白原血症功能缺陷血小板数量↓功能缺陷肝硬化患者凝血功能改变9肝病相关的血小板减少肝硬化门脉高压,脾功能亢进血小板减少抗血小板抗体肝细胞癌化疗血小板生成素水平↓/活性病毒抑制/抗病毒治疗ournalofHepatology48(2008)1000-1007肝病相关的血小板减少10肝病凝血改变课件11肝病凝血改变课件12肝病凝血改变课件13肝病凝血改变课件14肝病凝血改变课件15肝病凝血改变课件16肝病凝血改变课件17肝病凝血改变课件18肝病凝血改变课件19肝病凝血改变课件20肝病凝血改变课件21肝病凝血改变课件22肝病凝血改变课件23肝病凝血改变课件24肝病凝血改变课件25肝病凝血改变课件26肝病凝血改变课件27肝病凝血改变课件28肝病凝血改变课件29肝病患者的凝血改变肝病患者的凝血改变30置管11天,拔管4天后置管11天,拔管4天后31慢性肝病患者血栓栓塞发生情况1979-2006E≌5DVTFigurePom1979-2006ofpuImonaryembolism(PE),decthrombosis(DVT),andvenousthromboembolism(VTE)inhospitalizedadultpaticntswithalcoholicliverdiscaseandnonalcoholicliverdisease(alldifte慢性肝病患者静脉血栓的流行情况低于其他疾病TheAmericanJournalofMedicine(2011)124,64-68慢性肝病患者血栓栓塞发生情况32门静脉血栓门静脉血栓33门静脉血栓流行情况3796例尸检患者在主要引起门静脉血栓的病因中PVT的流行情况n=254Patientcategoryn(%)ofn(%)withinAge(yr)PVTpatientsriskcategoryMedianMean(95%C)withoutprimaryhepaticcancerPrimaryhepatobiliarycancer59(23)721(694-748)hepaticcarcinomaextrahepaticbiliary/gallbladdercarcinomaSecondarymalignancyofthehepatobiliaryregion111(4)690(667-71.2frompancreaticcarcinomagastriccarcinomacolorectalcarcinomalungcancermalignantlymphomamammaryadenocarcinomaotherprimaryMyeloproliferativedisorders654(442-86.6)Majorabdominalinfection/inflammation1.9(665-773Nocauseidentified708(659-757AllpatientswithPVT254(100)699(683-71.4门静脉血栓流行情况34肝硬化和肝癌患者发生门静脉血栓的风险较高存在门静脉风险疾病的发生PVT的流行和发生的相对风险(ods比值)N=23796Pacientcategoryn(%)PT(%)O.R.(95%C.)O.R.(95%CL)withoutprimaryhepaticca46{45)0001Primaryhepatobiliarycancer698②29)5985)10.880-165)<000withcirrhosis26(143)171(11-264)<00028(.3-56)00458(32-106)<00extrahepaticbiliarygallbladdercarcinoma21(67)72(45-114)<0.00Secondaryhepaticmalignancyfromalltumours3446(145)13033)49(38-62frompancreaticcarcinoma36(1.5)13.9096-202)m52(34-782<003gastriccarcunoma31618⑤57)59(369719(12-32)30.0192colorectalcarcinoma1320)5(03-10)3Myeloproliferativedisorders23101.0)30)30(14-63)0012Allpatients237960100)254(.0)WorldGastroenter肝硬化和肝癌患者发生门静脉血栓的风险较高35肝硬化患者出血发生情况肝硬化(25%35%)门脉高压凝血功能障碍食管静脉曲张(90%)因素较小肝硬化患者出血发生情况36正常的凝血酶生成和抑制反应Thrombin-TFPI(IXa)PL(VIlla)ThrombinVIllPSAPC<Thrombin-TMPCTFV|→(XaThrombin-(AX川arbn9n》FFibrinx-link正常的凝血酶生成和抑制反应37肝硬化患者凝血功能改变VWF和Ⅷ因子水平↑tPA、NO、和前列环素水平↑促进和抑制凝血因子水平↓纤维蛋白原和纤溶抑制剂水平↓ADAMTS水平↓血小板数量减少和异常纤维蛋白原血症功能缺陷血小板数量↓功能缺陷肝硬化患者凝血功能改变38肝病相关的血小板减少肝硬化门脉高压,脾功能亢进血小板减少抗血小板抗体肝细胞癌化疗血小板生成素水平↓/活性病毒抑制/抗病毒治疗ournalofHepatology48(2008)1000-1