肝病肝功能评估

1、关于肝病的肝功能评估第一张，PPT共三十页，创作于2022年6月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第二张，PPT共三十页，创作于2022年6月Child-Turcotte-Pugh肝功能分级指标 评分标准123腹水无少量中等量以上或难治性

2、腹水血清胆红素(umol/L) 51血清白蛋白(g/l) 352835 28凝血酶原时间(较正常延长秒数)or(INR)*13（正常值范围内）1.746（延长 6 （延长 2秒） 2.3肝性脑病无1-2级3-4级 *INR, international normalised ratio.估 计 生 存 率 (%)总积分分组一年二年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: /int-med/gi/model/mayomodl-5-unos.htm to calculate MELD score directlyLiver Transpl,2003.9:19-20 Kira

3、n M.Banbha,Curr opi org transp 2008,13:227-233第四张，PPT共三十页，创作于2022年6月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

4、, et al :MELD and PELD: application of survival models to liver allocation. Liver Transpl 2001;7:567-580第五张，PPT共三十页，创作于2022年6月第六张，PPT共三十页，创作于2022年6月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 第七张，PPT共三十页，创作于2022年6月MELD score No. of patients Pe

5、rioperative mortality, n (%) 8 9 1-Year 3-Year 5-YearMELD score survival (%) survival (%) survival (%) Perioperative Mortality and long-term survival after Hepatic Resection for HCCJournal Of Gastrointestinal Surgery 2005 Dec; Vol. 9 (9), pp. 1207-15The perioperative mortality for patients with MELD

6、 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 y

7、ear survival (%) Transpl Int, 2006 Dec; Vol. 19 (12), pp. 988-94; 95.3 90.4 0.000194.9 84.7 0.000191.9 77.8 0.000188.1 72.1 0.000188.1 72.1 0.0001Change in MELD score whilst on the transplant waiting list has a significant effect on survival post-transplant第九张，PPT共三十页，创作于2022年6月MELD的局限性没有包括任何临床症状的判断

8、，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 第十张，PPT共三十页，创作于2022年6月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% pe

9、r 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 cirrh

10、osis De Franchis R. J Hepatol 2005; 43:167176.第十一张，PPT共三十页，创作于2022年6月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, pl

11、atelet count, gamma globulin level and HVPG were significant mortality predictors DAmico G, J Hepatol 2006;44:217231.第十二张，PPT共三十页，创作于2022年6月MELD 联合血清钠水平(SNa)MELD-ASMELD-NaiMELD第十三张，PPT共三十页，创作于2022年6月MELD-AS MELD-AS = MELD + 4.53 X 0,1*+ 4.46 X 0,1* HEPATOLOGY. 2004 Oct; 40:802- 810*If sodium 135mmol

12、/L,=1;otherwise =0 *If persistent ascites,=1;otherwise =0第十四张，PPT共三十页，创作于2022年6月HEPATOLOGY. 2004 Oct; 40:802- 810MELD-AS CTP MELD MELD-ASALL MELDMELD21 0.789 0.83 0.874 0.696 0.687 0.790 0.586 0.773 0.758Predictors of 180-day Cirrhotic Patient MortalityMELD-AS may improve predictive accuracy,especia

13、lly at lower MELD scores第十五张，PPT共三十页，创作于2022年6月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。 第十六张，PPT共三十页，创作于2022年6月MELD-NaMELD

14、-Na = MELD +1.0 x(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 avertin

15、g deathW.Ray Kim et al.N Eng J Med 2008;359:1018-26第十七张，PPT共三十页，创作于2022年6月W.Ray Kim et al.N Eng J Med 2008;359:1018-26the 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 mi

16、ght have been prevented第十八张，PPT共三十页，创作于2022年6月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

17、 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

18、sodium 130 mEq/LLiver Transplantation,Vol 11,No3 ,2005: pp336-343第十九张，PPT共三十页，创作于2022年6月iMELDiMELD score=MELD + (0.3年龄) - (0.7血清钠) + 100 Liver Transpl 2007 Aug; Vol. 13 (8), pp. 1174-80第二十张，PPT共三十页，创作于2022年6月iMELDMortality in 451 patients with cirrhosis listed for liver transplantation. iMELD MELD3-

19、month6-month12-month 0.76 0.70 0.79 0.71 0.78 0.69 iMELD improves the predictive accuracy of time to death Liver Transpl 2007 Aug; Vol. 13 (8), pp. 1174-80第二十一张，PPT共三十页，创作于2022年6月ESTIMATING PROGNOSIS IN PATIENTS WITH PRIMARY BILIARY CIRRHOSIS (PBC)MAYO PBC RISK SCORER = 0.871 log(serum bilirubin in

20、mg/dL) 2.53 x log (albumin in g/dL) + 0.039 + (age in years) + 2.38 x log(prothrombin time in seconds) + 0.859 (if edema present) Risk score is translated into a survival function to estimate survival for the individual patient with PBC. Other models have emphasized variceal bleeding as an important

21、 additional clinical prognosticator.PROGNOSTIC INDEX FOR SURVIVAL AFTER LIVER TRANSPLANTATION IN PATIENTS WITH PBCPI = 0.60 x log (serum bilirubin in mg/dL) + 0.82 x log (serum urea in mmol/L) + 1.14 + (transplantation before 1985) 0.92 (diuretic-responsive ascites) + 1.70 Risk Score 4-Month Surviva

22、l 9.9 57%第二十二张，PPT共三十页，创作于2022年6月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AHPhillips M et al. Antioxidants versus corticosteroids in the treatment of severe alcoholic hepatitis a randomized clinical trial. J Hepatol, 2006; 44:784-790. 第二十三张，PPT共三十

23、页，创作于2022年6月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 Mathurin P et al. Early change in bilirubin levels (ECBL) is an important prognostic factor in severe biopsy-proven alcoholic hepa

24、titis (AH) treated by prednisolone. Hepatology, 2003; 88:1363-1369.第二十四张，PPT共三十页，创作于2022年6月Lille 模型Lille模型于2007年由法国CHRU Lille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(day 7) (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 (day 0)（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/score