肝衰竭治疗.ppt

肝衰竭的治疗 XXX市人民医院 支持治疗1 病因治疗2 并发症治疗 4 其他治疗3 C ONTENTS 目录 一、支持治疗 a. Bed rest, reducing energy consumption, and alleviating(缓 解) the burden of the liver ( ); b. Monitoring PTA/INR, blood ammonia(血氨)and blood biochemical indices, analyzing arterial blood lactate（乳酸 ）, endotoxin（内毒素）, hepadnavirus markers（嗜肝DNA 病毒）, ceruloplasmin（铜兰蛋白）, antibodies of autoimmune liver diseases（自免肝抗体）, and examining abdomen by B-ultrasound (liver, gallbladder, spleen and pancreas, ascites), taking chest X-ray and electro- cardiography (ECG) ( ); 一、支持治疗 c. Enteral nutrition is preferred, including high-carbohydrate（ 碳水化合物）, low-fat, moderate protein diet, providing 35-40 kcal/kg total calories; for patients with HE, protein intake by intestinal should be limited; for patients with hypoalimentation （营养不良）, adequate liquid and vitamin supplementation should be delivered intravenously to guarantee a daily total energy intake ( ); d. It is necessary to actively rectify（纠正） low proteinemia, and supply albumin or fresh plasma and blood coagulation factors as appropriate ( ); ve. Monitoring arterial blood gas is done if required, correcting the disturbance of water and electrolytes as well as acid-base equilibrium, especially hyponatremia（低钠血症）, hypochloraemia（低氯血症）, hypopotassaemia（低钾血症） and alkalosis（碱中毒） ( ); Hyponatremia is a common complication of decompensated (失代偿)cirrhosis. Hyponatremia, refractory ascites（顽固性腹水） and acute kidney injury (AKI) are commonly interrelated with each other. Water restriction, as appropriate, combined with diuretics（利尿剂）, is effective for hyponatremia and thus, prevents the subsequent complications; 一、支持治疗 vFor HBV DNA (+) patients with liver failure, antiviral therapy is relatively effective in the early and middle stages; but for patients with advanced stage of liver failure, due to the severely damage of residual hepatocytes and regenerative capacity of the liver, antiviral treatment is unlikely to improve outcome； vFor drug-induced liver injury (DILI), any presumed or possible offending agent should be stopped immediately ( ), documenting all agents taken over the past six months including prescription drugs, non- prescription drugs, herbs, dietary supplements ( ) 二、病因治疗 vFor patients affected by paracetamol（醋氨酚）、acetaminophen (APAP)（对 乙酰氨基酚）, N-acetylcysteine (NAC) （乙酰半胱氨酸）therapy is preferred； NAC may also improve the outcome for patients with ALF caused by non- APAP. For toadstool(毒菌) poisoning, silymarin（水飞蓟宾） or penicillin G15- 18 can be used ( ) vFor ALF induced by acute fatty liver of pregnancy/HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome, the immediate termination of pregnancy is recommended. If the disease continues to progress, artificial liver support and liver transplantation are recommended ( ). 二、病因治疗 vGlucocorticoid（激素）: Experts have not come to an agreement on the application of glucocorticoid in the treatment of liver failure. It is optimally indicated for non-viral infectious liver failure such as autoimmune liver diseases, etc, and glucocorticoid (prednisone, 40 to 60 mg/d) may be considered. For early stage liver failure caused by other etiologies, if the disease develops rapidly and without complications such as serious infections and hemorrhages（出血）, glucocorticoid is also recommended ( ). 三、其他治疗 vHepatocyte regeneration therapy: To relieve the necrosis（坏死） and promote the regeneration of hepatocytes, drugs including hepatocyte growth-promoting factors（促肝细胞生长因子） and prostaglandin E1 (PGE1)（前列腺素1） liposome ( ) can be used, but their efficacies need further observation. 三、其他治疗 vMicroecological therapy（微生态治疗）: Patients with liver failure exhibit gut microflora（肠道菌群） imbalance with reduced normal flora and increased pathogenic intestinal bacteria. The application of intestinal probiotics may improve the prognosis. Microecological modulators such as lactulose（乳果糖） or lactitol（乳糖醇） can be used to reduce the enteric bacteria translocation, endotoxemia （内毒素血症）, or HE（肝性脑病） ( ). vCerebral edema（脑水肿）: a) For patients with intracranial（颅内） hypertension, mannitol （甘露醇 ）(0.5-1.0 g/kg) can be used (-2); b) Diuretics, usually furosemide（呋塞米）, can be used with osmotic dehydrant alternatively ( ); c) Artificial liver support therapy is used ( ); d) Glucocorticoid is not recommended for intracranial hypertension (); e) Hypothermia therapy（低温治疗） is effective in preventing cerebral edema, and decreasing intracranial pressure ( ). 四、并发症治疗 HE（肝性脑病）: a) eliminating the inciting factors such as serious infections, hemorrhage, electrolyte disturbance ( ); b) protein-restricted diet ( ); c) oral lactulose or lactitol, or transferred by high enema（高位灌肠）, which can acidify（酸化） the intestinal tract, accelerate the excretion of ammonia, modulate intestinal microecology, and reduce the absorption of enterotoxin ( ); d) using branched chain amino acid（支链氨基酸） or mixed preparation of branched chain amino and with arginine （精氨酸）to rectify the inbalance of amino acid ( ); e)tracheal intubation for patients with grade +HE ( ); f)artificial liver support therapy ( ). 四、并发症治疗 vBacterial or fungal infections（细菌、真菌感染）: va) Routine examination of blood and body fluids is performed ( ); vb) Prophylactic（预防） use of antibacterial agents is not recommended except for patients with CLF who may orally take quinolones（喹诺酮） to prevent intestinal infections ( ); vc) Once infected, broad spectrum antimicrobial agents or combined use of antibiotics are preferred, and the therapy is adjusted according to the results of the sensitivity test (-2). Superinfection （多重感染）of fungi（ 真菌） is prevented during potent antibiotics treatment or antibiotics plus adrenal cortical hormone（肾上腺皮质激素） treatment ( ). 四、并发症治疗 vHyponatremia（低钠血症） and intractable ascites（顽固性腹水）: vTolvaptan（托伐普坦） is an arginine vasopressin（精氨酸加压素/抗利 尿激素） V2 receptor blocker（阻滞剂）, which can promote free water drainage（排泄） through selectively blocking collecting duct（ 集合管） principal cells V2 receptors, and has become a new method for the treatment of hyponatremia and intractable ascites. 四、并发症治疗 vAKI and hepatorenal syndrome: va) Systemic vasoactive（血管活性药物） drugs such as terlipressin（特利加 压素）, norepinephrine（去甲）, albumin （白蛋白）can be used for patients with intractable hypovolemic （血容量减少）hypotension（低血压）, but not for severe encephalopathy patients with intracranial hypertension who have the risk of exacerbation of cerebral edema with the increase of cerebral blood flow (-2) vb) Mean arterial pressure of 75 mmHg was maintained () vc)Fluid intake is restricted, and the total intake should not exceed the urine volume plus 500-700 mL within 24 hours ( ); v d) Artificial liver support therapy is recommended ( ). 四、并发症治疗 vHemorrhage: v a) Prophylactic use of histamine-2 (H2) receptor blocking agents（H2受体阻滞剂 ） or proton pump inhibitors （质子泵抑制剂）is recommended (); vb) For patients with portal hypertension hemorrhage, somatostatin analogues（生 长抑素类似物） are preferred( ); transjugular intrahepatic portosystemic shunt (TIPS) can be used for pa