肝病的肝功能评估讲稿.ppt
关于肝病的肝功能评估第一页，讲稿共三十页哦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(ModelforEnd-stageLiverDisease，MELD)CombinedMELD2007年LilleModel肝功能评估的发展历史肝功能评估的发展历史第二页，讲稿共三十页哦Child-Turcotte-Pugh肝功能分级肝功能分级指标指标 评分标准评分标准123腹水腹水无无少量少量中等量以上或难治性中等量以上或难治性腹水腹水血清胆红素血清胆红素(umol/L)51血清白蛋白血清白蛋白(g/l)352835 28凝血酶原时间凝血酶原时间(较正常较正常延长秒数延长秒数)or(INR)*13（正常值范围内）（正常值范围内）1.746（延长（延长 6（延长（延长 2秒）秒）2.3肝性脑病肝性脑病无无1-2级级3-4级级*INR,internationalnormalisedratio.估估 计计 生生 存存 率率(%)总积分总积分分组分组一年一年二年二年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.htm to calculate MELD score directlyLiver Transpl,2003.9:19-20KiranM.Banbha,Curropiorgtransp2008,13:227-233第四页，讲稿共三十页哦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,et al:MELD and PELD:application of survival models to liver allocation.Liver Transpl 2001;7:567-580第五页，讲稿共三十页哦第六页，讲稿共三十页哦2002年年2月月27日：美国器官共享网日：美国器官共享网/全美器官获全美器官获取和移植网取和移植网(Organ Procurement and Transplantation Network,OPTN)确定确定MELD为选择肝移植患者的新标准为选择肝移植患者的新标准第七页，讲稿共三十页哦MELD score No.of patients Perioperative mortality,n(%)8 9 1-Year3-Year5-YearMELDscoresurvival(%)survival(%)survival(%)Perioperative Mortality and long-term survival after Hepatic Resection for HCCJournalOfGastrointestinalSurgery2005Dec;Vol.9(9),pp.1207-15TheperioperativemortalityforpatientswithMELDscore9wassignificantlygreaterthanthatforpatientswithMELDscore8(0.01).Thelong-termsurvivalforpatientswithMELDscore9wassignificantlyshorterthanthatforpatientswithMELDscore8(+1 P-value90 day survival(%)180 day survival(%)1 year survival(%)2 year survival(%)3 year survival(%)TransplInt,2006Dec;Vol.19(12),pp.988-94;95.390.40.000194.984.70.000191.977.80.000188.172.10.000188.172.10.0001ChangeinMELDscorewhilstonthetransplantwaitinglisthasasignificanteffectonsurvivalpost-transplant第九页，讲稿共三十页哦MELD的局限性的局限性没有包括任何没有包括任何临床症状临床症状的判断，也没有考虑到患者的的判断，也没有考虑到患者的生生活质量活质量 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 第十页，讲稿共三十页哦Fourclinicalstagesofcirrhosisstage1:patientswithoutvaricesorascites(mortalityisabout1%peryear)Stage2:patientswithvaricesbutwithoutascitesorbleeding(mortalityrateofabout4%peryear)Stage3:patientshaveasciteswithorwithoutesophagealvaricesthathaveneverbled(mortalityratewhileremaininginthisstageis20%peryear)Stage4:withportalhypertensiveGIbleedingwithorwithoutascites(1-yearmortalityrateof57%)compensatedcirrhosisdecompensatedcirrhosisDeFranchisR.JHepatol2005;43:167176.第十一页，讲稿共三十页哦HVPGpatientswithanHVPG10mmHghada90%probabilityofnotdevelopingclinicaldecompensationduringafollow-upperiodofupto4yearsIncompensatedcirrhosis,markersofportalhypertensionsuchasvarices,splenomegaly,plateletcount,gammaglobulinlevelandHVPGweresignificantmortalitypredictorsDAmicoG,JHepatol2006;44:217231.第十二页，讲稿共三十页哦MELD 联合血清钠水平联合血清钠水平(SNa)MELD-ASMELD-NaiMELD第十三页，讲稿共三十页哦MELD-ASMELD-AS=MELD+4.53 X 0,1*+4.46 X 0,1*HEPATOLOGY.2004Oct;40:802-810*Ifsodium135mmol/L,=1;otherwise=0*Ifpersistentascites,=1;otherwise=0第十四页，讲稿共三十页哦HEPATOLOGY.2004Oct;40:802-810MELD-ASCTPMELDMELD-ASALLMELDMELD210.7890.830.8740.6960.6870.7900.5860.7730.758Predictorsof180-dayCirrhoticPatientMortalityMELD-ASmayimprovepredictiveaccuracy,especiallyatlowerMELDscores第十五页，讲稿共三十页哦Association between serum sodium levels and severity of ascites and complications of cirrhosis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。第十六页，讲稿共三十页哦MELD-NaMELD-Na=MELD+1.0 x(140-Na)0.025MELD(140Na).UseoftheMEL-DNascoremayreducemortalityamongpatientsonthewaitinglist.ThedifferencebetweentheMELDscoreandtheMELD-NascorewasoftenlargeenoughtomakearealdifferenceintheprobabilityofreceivingalivertransplantandavertingdeathW.RayKimetal.NEngJMed2008;359:1018-26第十七页，讲稿共三十页哦W.RayKimetal.NEngJMed2008;359:1018-26theexpectednumberoftransplantations:67(58.4%18.5%)+43(70.4%58.4%)=32Thus,7%ofdeaths(32of477)thatoccurredwithin3monthsafterregistrationonthewaitinglistmighthavebeenprevented第十八页，讲稿共三十页哦Prevalence of Ascites,Severity of Liver Failure,Renal Function,and Mortality According to HyponatremiaStatus in Patients Not Transplanted Within 3 MonthsNo 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%)0.001 Hyponatremia was defined as serum sodium 130 mEq/LLiver Transplantation,Vol 11,No3,2005:pp336-343Liver Transplantation,Vol 11,No3,2005:pp336-343第十九页，讲稿共三十页哦iMELDiMELD score=MELD+(0.3年龄年龄)-(0.7血血清钠清钠)+100 LiverTranspl2007Aug;Vol.13(8),pp.1174-80第二十页，讲稿共三十页哦iMELDMortalityin451patientswithcirrhosislistedforlivertransplantation.iMELD MELD3-month6-month12-month 0.760.700.790.710.780.69iMELDimprovesthepredictiveaccuracyoftimetodeathLiverTranspl2007Aug;Vol.13(8),pp.1174-80第二十一页，讲稿共三十页哦ESTIMATING PROGNOSIS IN PATIENTS WITH PRIMARY BILIARY CIRRHOSIS(PBC)MAYO PBC RISK SCORER=0.871log(serumbilirubininmg/dL)2.53xlog(albumining/dL)+0.039+(ageinyears)+2.38xlog(prothrombintimeinseconds)+0.859(ifedemapresent)RiskscoreistranslatedintoasurvivalfunctiontoestimatesurvivalfortheindividualpatientwithPBC.Othermodelshaveemphasizedvaricealbleedingasanimportantadditionalclinicalprognosticator.PROGNOSTIC INDEX FOR SURVIVAL AFTER LIVER TRANSPLANTATION IN PATIENTS WITH PBCPI=0.60 xlog(serumbilirubininmg/dL)+0.82xlog(serumureainmmol/L)+1.14+(transplantationbefore1985)0.92(diuretic-responsiveascites)+1.70RiskScore4-MonthSurvival9.957%第二十二页，讲稿共三十页哦酒精性肝病严重程度评估方法Maddrey判别函数DF=4.6PT延长（秒）TB（mgdl），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.Antioxidantsversuscorticosteroidsinthetreatmentofseverealcoholichepatitisarandomizedclinicaltrial.JHepatol,2006;44:784-790.第二十三页，讲稿共三十页哦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：95ECBL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.第二十四页，讲稿共三十页哦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=3.190.101*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)0.0096*凝血酶原时间(seconds).说明：肾功能不全评价标准：肌酐是否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http:/
