Dengue induced acute liver failure:A meta summary of case reports

BACKGROUND Dengue fever is the most common cause of viral hemorrhagic fever,with more than 400 million cases being reported annually,worldwide.Even though hepatic involvement is common,acute liver failure(ALF)is a rare complication of dengue fever.AIM To analyze the demographic profile,symptomology,hospital course and outcomes of patients presenting with ALF secondary to dengue infection by reviewing the published case reports.METHODS A systematic search was performed from multiple databases including PubMed,Reference Citation Analysis,Science Direct,and Google Scholar.The search terms used were"dengue"OR"severe dengue"OR"dengue shock syndrome"OR"dengue haemorrhagic syndrome"OR"dengue fever"AND"acute liver failure"OR"hepatic failure"OR"liver injury".The inclusion criteria were:(1)Case reports or case series with individual patient details;(2)Reported acute liver failure secondary to dengue infection;and(3)Published in English language and on adult humans.The data were extracted for patient demographics,clinical sympto-matology,clinical interventions,hospital and intensive care unit course,need for organ support and clinical outcomes.RESULTS Data from 19 case reports fulfilling the predefined inclusion criteria were included.The median age of patients was 38 years(inter quartile range:Q3-Q126.5 years)with a female preponderance(52.6%).The median days from diagnosis of dengue to development of ALF was 4.5 d.The increase in aspartate aminotransferase was higher than that in alanine aminotransferase(median 4625 U/L vs 3100 U/L).All the patients had one or more organ failure,with neurological failure present in 73.7%cases.42.1%patients required vasopressor support and hepatic enceph-alopathy was the most reported complication in 13(68.4%)cases.Most of the patients were managed conser-vatively and 2 patients were taken up for liver transplantation.Only 1 death was reported(5.3%).CONCLUSION Dengue infection may rarely lead to ALF.These patients may frequently require intensive care and organ support.Even though most of these patients may improve with supportive care,liver transplantation may be a therapeutic option in refractory cases.

Risk factors for progression to acute-on-chronic liver failure during severe acute exacerbation of chronic hepatitis B virus infection

BACKGROUND Acute exacerbation in patients with chronic hepatitis B virus(HBV) infection results in different severities of liver injury. The risk factors related to progression to hepatic decompensation(HD) and acute-on-chronic liver failure(ACLF) in patients with severe acute exacerbation(SAE) of chronic HBV infection remain unknown.AIM To identify risk factors related to progression to HD and ACLF in compensated patients with SAE of chronic HBV infection.METHODS The baseline characteristics of 164 patients with SAE of chronic HBV infection were retrospectively reviewed. Independent risk factors associated with progression to HD and ACLF were identified. The predictive values of our previously established prediction model in patients with acute exacerbation(AE model) and the model for end-stage liver disease(MELD) score in predicting the development of ACLF were evaluated.RESULTS Among 164 patients with SAE, 83(50.6%) had compensated liver cirrhosis(LC),43 had progression to HD without ACLF, and 29 had progression to ACLF within 28 d after admission. Independent risk factors associated with progression to HD were LC and low alanine aminotransferase. Independent risk factors for progression to ACLF were LC, high MELD score, high aspartate aminotransferase(AST) levels, and low prothrombin activity(PTA). The area under the receiver operating characteristic of the AE model [0.844, 95%confidence interval(CI): 0.779-0.896] was significantly higher than that of MELD score(0.690, 95%CI: 0.613-0.760, P < 0.05) in predicting the development of ACLF.CONCLUSION In patients with SAE of chronic HBV infection, LC is an independent risk factor for progression to both HD and ACLF. High MELD score, high AST, and low PTA are associated with progression to ACLF. The AE model is a better predictor of ACLF development in patients with SAE than MELD score.

Lymphocyte-to-white blood cell ratio is associated with outcome in patients with hepatitis B virus-related acute-on-chronic liver failure

BACKGROUND The lymphocyte-to-white blood cell ratio(LWR)is a blood marker of the systemic inflammatory response.The prognostic value of LWR in patients with hepatitis B virus-associated acute-on-chronic liver failure(HBV-ACLF)remains unclear.AIM To explore whether LWR could stratify the risk of poor outcomes in HBV-ACLF patients.METHODS This study was conducted by recruiting 330 patients with HBV-ACLF at the Department of Gastroenterology in a large tertiary hospital.Patients were divided into survivor and non-survivor groups according to their 28-d prognosis.The independent risk factors for 28-d mortality were calculated by univariate and multivariate Cox regression analyses.Patients were divided into low-and high-LWR groups according to the cutoff values.Kaplan-Meier analysis was performed according to the level of LWR.RESULTS During the 28-d follow-up time,135 patients died,and the mortality rate was 40.90%.The LWR level in non-surviving patients was significantly decreased compared to that in surviving patients.A lower LWR level was an independent risk factor for poor 28-d outcomes(hazard ratio=0.052,95%confidence interval:0.005-0.535).The LWR level was significantly negatively correlated with the Child-Turcotte-Pugh,model for end-stage liver disease,and Chinese Group on the Study of Severe Hepatitis B-ACLF II scores.In addition,the 28-d mortality was higher for patients with LWR<0.11 than for those with LWR≥0.11.CONCLUSION LWR may serve as a simple and useful tool for stratifying the risk of poor 28-d outcomes in HBVACLF patients.

Score model for predicting acute-on-chronic liver failure risk in chronic hepatitis B

AIM: To establish a clinical scoring model to predict risk of acute-on-chronic liver failure(ACLF) in chronic hepatitis B(CHB) patients.METHODS: This was a retrospective study of 1457 patients hospitalized for CHB between October 2008 and October 2013 at the Beijing Ditan Hospital, Capital Medical University, China. The patients were divided into two groups: severe acute exacerbation(SAE) group(n = 382) and non-SAE group(n = 1075). The SAE group was classified as the high-risk group based on the higher incidence of ACLF in this group than in the non-SAE group(13.6% vs 0.4%). Two-thirds of SAE patients were randomly assigned to risk-model derivation and the other one-third to model validation. Univariate risk factors associated with the outcome were entered into a multivariate logistic regression model for screening independent risk factors. Each variable was assigned an integer value based on the regression coefficients, and the final score was the sum of these values in the derivation set. Model discrimination and calibration were assessed using area under the receiver operating characteristic curve and the Hosmer-Lemeshow test. RESULTS: The risk prediction scoring model includedthe following four factors: age ≥ 40 years, total bilirubin ≥ 171 μmol/L, prothrombin activity 40%-60%, and hepatitis B virus DNA > 107 copies/m L. The sum risk score ranged from 0 to 7; 0-3 identified patients with lower risk of ACLF, whereas 4-7 identified patients with higher risk. The Kaplan-Meier analysis showed the cumulative risk for ACLF and ACLF-related death in the two risk groups(0-3 and 4-7 scores) of the primary cohort over 56 d, and log-rank test revealed a significant difference(2.0% vs 33.8% and 0.8% vs 9.4%, respectively; both P < 0.0001). In the derivation and validation data sets, the model had good discrimination(C index = 0.857, 95% confidence interval: 0.800-0.913 and C index = 0.889, 95% confidence interval: 0.820-0.957, respectively) and calibration demonstrated by the Hosmer-Lemeshow test(χ2 = 4.516, P = 0.808 and χ2 = 1.959, P = 0.923, respectively).CONCLUSION: Using the scoring model, clinicians can easily identify patients(total score ≥ 4) at high risk of ACLF and ACLF-related death early during SAE.

Prognostic value of M30/M65 for outcome of hepatitis B virus-related acute-on-chronic liver failure

AIM: To determine the prognostic value of circulating indicators of cell death in acute-on-chronic liver failure (ACLF) patients with chronic hepatitis B virus (HBV) infection as the single etiology. METHODS: Full length and caspase cleaved cytokeratin 18 (detected as M65 and M30 antigens) represent circulating indicators of necrosis and apoptosis. M65 and M30 were identified by enzyme-linked immunosorbent assay in 169 subjects including healthy controls (n = 33), patients with chronic hepatitis B (CHB, n = 55) and patients with ACLF (n = 81). According to the 3-mo survival period, ACLF patients were defined as having spontaneous recovery (n = 33) and non-spontaneous recovery which included deceased patients and those who required liver transplantation (n = 48). RESULTS: Both biomarker levels significantly increased gradually as liver disease progressed (for M65: P < 0.001 for all; for M30: control vs CHB, P = 0.072; others: P < 0.001 for all). In contrast, the M30/M65 ratio was significantly higher in controls compared with CHB patients (P = 0.010) or ACLF patients (P < 0.001). In addition, the area under receiver operating characteristic curve (AUC) analysis demonstrated that both biomarkers had diagnostic value (AUC >= 0.80) in identifying ACLF from CHB patients. Interestingly, it is worth noting that the M30/M65 ratio was significantly different between spontaneous and non-spontaneous recovery in ACLF patients (P = 0.032). The prognostic value of the M30/M65 ratio was compared with the Model for End-Stage Liver Disease (MELD) and Child-Pugh scores at the 3-mo survival period, the AUC of the M30/M65 ratio was 0.66 with a sensitivity of 52.9% and the highest specificity of 92.6% (MELD:AUC = 0.71; sensitivity, 79.4%; specificity, 63.0%; Child-Pugh: AUC = 0.77; sensitivity, 61.8%; specificity, 88.9%). CONCLUSION: M65 and M30 are strongly associated with liver disease severity. The M30/M65 ratio may be a potential prognostic marker for spontaneous recovery in patients with HBV-related ACLF. (C) 2014 Baishideng Publishing Group Co., Limited. All rights reserved.

Combined use of non-biological artif icial liver treatments for patients with acute liver failure complicated by multiple organ dysfunction syndrome

BACKGROUND:Acute liver failure(ALF) caused by viral and non-viral hepatitis is often accompanied with severe metabolic disorders,the accumulation of toxic substances and continuous release and accumulation of a large number of endogenous toxins and inflammatory mediators. The present study aimed to investigate the effects of various combined non-biological artif icial liver treatments for patients with acute liver failure(ALF) complicated by multiple organ dysfunction syndrome(MODS).METHODS:Thirty-one patients with mid- or late-stage liver failure complicated by MODS(score 4) were randomly divided into three treatment groups:plasmapheresis(PE) combined with hemoperfusion(HP) and continuous venovenous hemodiafiltration(CVVHDF),PE+CVVHDF,and HP+CVVHDF,respectively. Heart rate(HR) before and after treatment,mean arterial pressure(MAP),respiratory index(PaO2/FiO2),hepatic function,platelet count,and blood coagulation were determined.RESULTS:Signifi cant improvement was observed in HR,MAP,PaO2/FiO2,total bilirubin(TBIL) and alanine aminotransferase(ALT) levels after treatment(P<0.05). TBIL and ALT decreased more signifi cantly after treatment in the PE+CVVHDF and PE+HP+CVVHDF groups(P<0.01). Prothrombin time(PT) and albumin were signifi cantly improved only in the PE+CVVHDF and PE+HP+CVVHDF groups(P<0.05). TBIL decreased more significantly in the PE+HP+CVVHDF group than in the HP+CVVHDF and PE+CVVHDF groups(P<0.05). The survival rate of the patients was 58.1%(18/31),viral survival rate 36.4%(4/11),and non-viral survival rate 70%(14/20).CONCLUSION:Liver function was relatively improved after treatment,but PE+HP+CVVHDF was more efficient for the removal of toxic metabolites,especially bilirubin. The survival rate was signifi cantly higher in the patients with non-viral liver failure than in those with viral liver failure.

Acute fatty liver of pregnancy associated with severe acute pancreatitis:A case report

Acute fatty liver of pregnancy is a rare disease that affects women in the third trimester of pregnancy. Although infrequent, the disease can cause maternal mortality. The diagnosis is not always clear until the pregnancy is terminated, and significant complications, such as acute pancreatitis, can occur. Pancreatic involvement typically only occurs in severe cases after the development of hepatic and renal impairment. To date, little knowledge is available regarding how the disease causes pancreatitis. Treatment involves supportive measures and pregnancy interruption. In this report, we describe a case of a previously healthy 26-year-old woman at a gestational age of 27 wk and 6 d who was admitted with severe abdominal pain and vomiting. This case illustrates the clinical and laboratory overlap between acute fatty liver of pregnancy and pancreatitis, highlighting the difficulties in differentiating each disease. Furthermore, the hypothesis for this overlapping is presented, and the therapeutic options are discussed.

Fulminant Hepatitis Associated with Chronic Consumption of 3,4-Methylenedioxy-Methamphetamine;Case Report

The amphetamine derivative 3,4-methylenedioxymethamphetamine (MDMA), also called ecstasy, is a neurotoxin widely consumed among young people that has increased in recent years because it is a recreational drug, of which immediate effects are known such as a greater sensation of well-being, extroversion, increased sensory perception. However, its long-term effects have been described very little in the medical literature, including damage to the heart, central nervous system, kidney, etc. One of its little-known effects is hepatotoxicity, of which few cases are known associated with fulminant hepatitis, which is a rapidly deteriorating condition that is generally associated with a syndrome of multiple organ dysfunction and death. Therefore, it is very important to know this type of damage in the short and long term. The following case is of a 39-year-old man who came to our service due to jaundice syndrome and the only history of MDMA consumption, who as the days went by met the criteria for fulminant liver failure, with damage to multiple organs (organ dysfunction syndrome).

血清IL-33与NLR水平对肝病患者病情的预测价值探究

目的:探讨血清白细胞介素33(Interleukin-33,IL-33)与中性粒细胞/淋巴细胞比值(Neutrophil-to-lymphocyte ratio,NLR)水平变化对重型肝病患者病情进展的预测价值。方法:选取本院2019年6月至2023年9月收治的72例肝衰竭患者为重症组,72例慢性乙肝患者为肝炎组,另收集144例同期健康体检者为对照组。对比三组患者及不同预后患者血清IL-33、NLR及谷丙转氨酶(Alanine aminotransferase,ALT)、天冬氨酸氨基转移酶(Aspartate transaminase,AST)、总胆红素(Total bilirubin,TBIL)水平,分析其相关性及对预后的预测价值。结果:重症组血清IL-33、NLR及AST、ALT、TBIL水平显著高于肝炎组及对照组(P<0.05)。血清IL-33、NLR与AST、ALT、TBIL呈正相关(P<0.05)。重症组预后不良患者血清IL-33、NLR均高于预后良好患者(P<0.05)。血清IL-33、NLR联合检测对患者预后不良的预测价值较高。结论:血清IL-33、NLR水平与重型肝病患者病情相关,临床检测其水平对评估病情进展具有重要价值。

Progress on clinical prognosis assessment in liver failure

Liver failure is a group of clinical syndromes with a mortality rate of>50%.The accurate evaluation of severity in patients with liver failure has been a meaningful and hot topic in clinical research and an important guide for liver transplantation.Numerous prognosis studies have emerged in recent years with high accuracy and adequate validity.Nonetheless,different models utilize distinct parameters and have unequal efficiencies,leading to a specific value and unique application situations for each model.This review focused on the progress in recent prognostic studies including the model for end-stage liver disease,sequential organ failure assessment and its derivative models,the Chinese Group on the Study of Severe Hepatitis B Acute-on-Chronic Liver Failure,the Tongji prognostic predictor model,and other emerging prognostic models and predictors.This review aims to assist clinicians understand the framework of recent models and choose the appropriate model and treatment.

Incidence and risk factors for early renal dysfunction after liver transplantation

AIM: To determine renal dysfunction post liver transplantation, its incidence and risk factors in patients from a Belgian University Hospital.METHODS: Orthotopic liver transplantations performed from January 2006 until September 2012 were retrospectively reviewed(n = 187). Patients with no renal replacement therapy(RRT) before transplantation were classified into four groups according to their highest creatinine plasma level during the first postoperative week. The first group had a peak creatinine level below 12 mg/L, the second group between 12 and 20 mg/L, the third group between 20 and 35 mg/L, and the fourth above 35 mg/L. In addition, patients who needed RRT during the first week after transplantation were also classified into the fourth group. Perioperative parameters were recorded as risk factors, namely age, sex, bodymass index(BMI), length of preoperative hospital stay, prior bacterial infection within one month, preoperative ascites, preoperative treatment with β-blocker, angiotensin-converting enzyme inhibitor or non steroidal anti-inflammatory drugs, preoperative creatinine and bilirubin levels, donor status(cardiac death or brain death), postoperative lactate level, need for intraoperative vasopressive drugs, surgical revision, mechanical ventilation for more than 24 h, postoperative bilirubin and transaminase peak levels, postoperative hemoglobin level, amount of perioperative blood transfusions and type of immunosuppression. Univariate and multivariate analysis were performed using logistic ordinal regression method. Post hoc analysis of the hemostatic agent used was also done.RESULTS: There were 78 patients in group 1(41.7%), 46 in group 2(24.6%), 38 in group 3(20.3%) and 25 in group 4(13.4%). Twenty patients required RRT: 13(7%) during the first week after transplantation. Using univariate analysis, the severity of renal dysfunction was correlated with presence of ascites and prior bacterial infection, preoperative bilirubin, urea and creatinine level, need for surgical revision, use of vasopressor, postoperative mechanical ventilation, postoperative bilirubin and urea, aspartate aminotransferase(ASAT), and hemoglobin levels and the need for transfusion. The multivariate analysis showed that BMI(OR = 1.1, P = 0.004), preoperative creatinine level(OR = 11.1, P < 0.0001), use of vasopressor(OR = 3.31, P = 0.0002), maximal postoperative bilirubin level(OR = 1.44, P = 0.044) and minimal postoperative hemoglobin level(OR = 0.059, P = 0.0005) were independent predictors of early post-liver transplantation renal dysfunction. Neither donor status nor ASAT levels had significant impact on early postoperative renal dysfunction in multivariate analysis. Absence of renal dysfunction(group 1) was also predicted by the intraoperative hemostatic agent used, independently of the extent of bleeding and of the preoperative creatinine level.CONCLUSION: More than half of receivers experienced some degree of early renal dysfunction after liver transplantation. Main predictors were preoperative renal dysfunction, postoperative anemia and vasopressor requirement.

Liver involvement in the drug reaction,eosinophilia,and systemic symptoms syndrome

First described in 1996,the drug reaction,eosinophilia,and systemic symptoms syndrome(DReSS) is considered,along with Stevens-Johnson syndrome and toxic epidermal necrolysis,a severe cutaneous drug reaction. It is characterized by the presence of a maculopapular erythematous skin eruption,fever,lymphadenopathy,influenza-like symptoms,eosinophilia,and visceral involvement such as hepatitis,pneumonitis,myocarditis,pericarditis,nephritis,and colitis. The prognosis of patients with DReSS is related to the severity of visceral involvement. The mortality ranges from approximately 5% to 10%,and death is mainly due to liver failure,which is also the organ most commonly involved in this syndrome. Although it was previously hypothesized in 1994,DReSS syndrome can lead to reactivation of one or more human herpesvirus family members. Now being included as diagnostic criteria in a proposed diagnostic score system,this reactivation can be detected up to 2-3 wk after DReSS syndrome onset. Other causes of mortality in DReSS syndrome include myocardial or pulmonary lesions and hemophagocytosis. We reviewed the literature of previously reported case-series of DReSS and liver involvement,highlighting the pattern of liver damage,the treatment used,and the outcome.

Dengue hemorrhagic fever and the liver

Dengue hemorrhagic fever(DHF)is one of the most rapidly emerging infections of tropical and subtropical regions worldwide.It affects more rural and urban areas due to many factors,including climate change.Although most people with dengue viral infection are asymptomatic,approximately 25%experience a selflimited febrile illness with mild to moderate biochemical abnormalities.Severe dengue diseases develop in a small proportion of these patients,and the common organ involvement is the liver.The hepatocellular injury was found in 60%-90%of DHF patients manifested as hepatomegaly,jaundice,elevated aminotransferase enzymes,and critical condition as an acute liver failure(ALF).Even the incidence of ALF in DHF is very low(0.31%-1.1%),but it is associated with a relatively high mortality rate(20%-68.3%).The pathophysiology of liver injury in DHF included the direct cytopathic effect of the DENV causing hepatocytes apoptosis,immunemediated hepatocyte injury induced hepatitis,and cytokine storm.Hepatic hypoperfusion is another contributing factor in dengue shock syndrome.The reduction of morbidity and mortality in DHF with liver involvement is dependent on the early detection of warning signs before the development of ALF.

Prevalence and Severity of HBV-Associated Acute-on-Chronic Liver Failure Due to Irregular Medication of Nucleos(t)ide Analogs

Hepatitis B virus(HBV)represents the commonest etiologic agent of acute-on-chronic liver failure(ACLF)in most Asian countries.Nucleos(t)ide analogs(NAs)are effective in the treatment of chronic HBV infections,but may also exacerbate the disease and stimulate its development into HBV-associated ACLF if not used appropriately.The current study aimed to assess the prevalence and severity of HBV-associated ACLF as a result from irregular medication of NAs(IMNA).A total of 1134 individuals with HBV-associated ACLF in nine hospitals in Heilongjiang Province were enrolled in this study between 2005 and 2015.Among these,777 chronic hepatitis B(CHB)and 357 HBV-associated liver cirrhosis cases were classified based on various predisposing factors,including IMNA,HBV reactivation(HBVR),infections,treatment drugs,alcohol use and others(hepatitis C virus,hepatitis E virus,gastrointestinal bleeding and unknown reasons).The percentage and improvement rate were examined.Among individuals with HBV-associated ACLF and CHB,IMNA was found in 9.01%,HBVR in 46.20%,infections in 9.52%,treatment drugs in 14.67%,alcohol in 11.71%,and others in 24.58%as predisposing factors.Improvement rates in cases with IMNA,HBVR,infections,treatment drugs,alcohol and others were 41.43%,58.50%,58.11%,56.14%,53.85%,and 65.97%,respectively.Multivariable analysis showed that IMNA,others,infections,hepatic encephalopathy and hepatorenal syndrome were associated with prognosis.Only IMNA independently predicted HBV-associated ACLF prognosis.Overall,our study demonstrated that the percentage of IMNAinduced HBV-associated ACLF was 12.61%,and worse disease conditions resulted from IMNA compared with other factors.Thus,the suitability of treatment with NAs should be thoroughly evaluated.

高度依赖病房及其在重症肝病患者临床管理中的应用

高度依赖病房(high dependency unit, HDU)可为单器官衰竭(呼吸衰竭除外)患者提供介于普通病房与重症监护病房之间的中等水平的护理。重症肝病(severe liver disease, SLD)患者肝功能严重障碍,多表现出急性或慢性单器官衰竭。HDU可满足SLD患者的监护需求,但目前国内仅有少数医院开设HDU。本文通过介绍HDU的概念、类型、作用以及SLD HDU建设与应用的研究进展,表明HDU在SLD患者临床管理中的应用将有助于医疗团队为患者实施更安全高效的救治,同时为推广建设HDU提供了理论及实践依据。

胆红素吸附联合血浆置换对重症肝衰的治疗效果观察

目的观察胆红素吸附(PBA)联合血浆置换(PE)在重症肝衰治疗中的应用效果,探究该治疗方案的实施价值。方法获伦理委员会审批,选取2020年6月—2022年12月本院收治的84例确诊为重症肝衰患者作为研究对象。结合患者的情况差异,遵循随机性原则,采用系统随机化法分为对照组与观察组,每组42例,对照组接受PE治疗,观察组接受PBA+PE治疗,根据多项观察指标,评估并比较两组疗效。结果治疗后,观察组各项肝功能指标优于对照组,具体表现为ALT、AST、DBIL、IBIL、TBIL更低,对比均具有显著差异(P<0.05)。治疗后,观察组各项血清内毒素指标和细胞因子指标均优于对照组,具体表现为LPS、IL-1、IL-6、TNF-α更低,对比均具有显著差异(P<0.05)。观察组治疗有效率高于对照组(P<0.05),不良反应发生率低于对照组(P<0.05)。结论PBA与PE在重症肝衰中的联合应用可取得良好疗效,在改善肝功能指标、提高治疗有效率、降低血清细胞因子水平、减少不良反应发生四大方面均有积极作用,值得进一步研究和大范围推广。

分子吸附再循环系统人工肝治疗急、慢性肝功能衰竭

目的观察分子吸附再循环系统(MARS)人工肝治疗急、慢性肝功能衰竭的临床效果和近期疗效.方法急、慢性肝功能衰竭行MARS人工肝治疗共28例56例次,采用间歇治疗模式,每次历时6～8 h.结果 28例患者中,男23例,女5例,平均年龄为(50.57±13.38)岁.其中急性肝功能衰竭12例,慢性肝功能衰竭急性加重16例.单次治疗后总胆红素、结合胆红素、总胆汁酸、血氨分别较治疗前下降31.47%、29.15%、35.91%和53.68%(P值均＜0.01).白蛋白、前白蛋白、胆碱酯酶和血压无显著变化.单次治疗后凝血酶原时间由治疗前的(32.37±9.96)s缩短为(21.82±10.39)s(P＜0.01),临床出血倾向明显减轻.24例(85.7%)在治疗6～12h后意识障碍好转,乏力、恶心、呕吐、腹胀等症状明显缓解,食欲增加,短期存活率(30d)为71.4%(20/28例).2例急性肝功能衰竭患者(7.1%)治疗痊愈出院,10例(35.7%)成功过渡至肝移植,8例(28.6%)治疗后15～30d好转,8例在治疗2～14d内死亡,死亡原因为多脏器功能衰竭和内脏出血.结论MARS治疗有助于抢救急、慢性肝功能衰竭患者,安全性好,近期疗效显著,可作为肝移植前的过渡手段.

血浆置换联合高通量血液透析滤过治疗重症肝炎肝脏衰竭临床研究

目的 :探讨非生物型人工肝支持疗法血浆置换 (PE)与高通量血液透析滤过 (HDF)相结合对国内重症肝炎肝脏衰竭的临床疗效、安全性及可行性。方法 :对 2 6例不同病因重症肝炎肝衰竭患者应用上述人工肝方法进行治疗 5 8次 ,通过比较治疗前后患者临床症状、肝功能、凝血酶原活动度 (PTA)、血氨等指标判断临床疗效 ,观察治疗相关的不良反应及患者耐受情况判断安全性及可行性。结果 :患者意识、黄疸、乏力、腹胀、纳差等症状均明显缓解 ,血清总胆红素治疗后较治疗前平均降低 (190 .8± 93.6 )μmol/L ,PTA上升 (19.7± 8.9) % ,治疗后存活率达 80 .8% ,不良反应主要以血浆过敏居多 ,未发生大出血、休克等严重并发症及应用血制品引起的重叠感染 ,患者耐受良好。结论 :PE联合 HDF可显著改善重症肝炎肝脏功能衰竭患者临床症状及生化指标 ,提高近期存活率 ,且安全可行 ,值得在国内推广使用。

重型肝炎和肝癌肝硬化患者肝移植围手术期肾功能的变化

目的 观察重型肝炎及肝癌肝硬化患者原位肝移植围手术期肾功能变化,评价肝移植术对该类患者肾功能的影响。方法 选择30例术前血肌酐（SCr）、尿素氮（BUN）正常的终末期肝病、行背驮式原位肝移植术患者,手术过程中均未采用体外静-静脉转流。按原发病不同分为重型肝炎组（15例）和肝癌肝硬化组（肝癌组15例）,分别于术前（麻醉后）、无肝前20min、无肝30min、新肝60min、术毕不同时间点取桡动脉血,测定β2-微球蛋白（β2-MG）值,并记录血流动力学变化;分别于术前、新肝60min、术毕留取新鲜尿液,测定尿β2-MG及尿N-乙酰-β-D-葡萄糖苷酶（NAG）值。记录两组患者术前、术后24h、术后1周的SCr、BUN值以及术后肝移植相关性肾功能衰竭（肾衰）的发生情况。结果1术前重型肝炎组有7例血β2-MG、12例尿β2-MG、14例尿NAG值均高于正常参考值;而肝癌组仅有3例血β2-MG、3例尿β2-MG、7例尿NAG值高于正常参考值;两组各时间点血β2-MG异常率比较差异均无显著性（P均〉0.05）;重型肝炎组术前尿β2-MG及NAG异常率明显高于肝癌组（P〈0.01和P〈0.05）。2术中两组血β2-MG值与术前比较变化不大,变化趋势两时间点间比较差异均无显著性;两组新肝期60min及术毕尿β2-MG及NAG均较术前呈增高趋势,但差异无显著性（P均〉0.05）,而重型肝炎组各时间点尿NAG值明显高于肝癌组（P〈0.05或P〈0.01）。3重型肝炎组肝移植相关性肾衰发生率为46.7%,而肝癌组无一例发生（P〈0.01）。结论 重型肝炎患者较肝癌肝硬化患者肝移植术后早期易发生急性肾衰,围手术期应注意肾功能保护。

慢性乙型重型肝炎中医证候规律研究

目的:探讨浙江地区慢性乙型重型肝炎(CSHB)中医证候特点及分布规律,为建立规范的中医证候标准进行前期探索。方法:临床收集2009年5月-2010年1月在杭州市第六人民医院住院CSHB患者的一般情况、中医四诊信息及相关实验室指标,以国家"十一五"科技重大专项"慢性重型肝炎证候规律及中西医结合治疗方案研究"制定的辨证分型方案进行辨证,分析中医证型的分布规律及其与临床特征的关系。结果:(1)总计99例CSHB纳入研究,其中慢加急(亚急)性肝衰竭80例(80.08%);年龄15～72岁,平均(44.48±12.26)岁,男性74(74.75%)例;(2)中医证型以瘀热发黄27例(27.27%)、气虚瘀黄26例(26.26%)和湿热发黄21例(21.21%)3型较为常见,其次为阴虚瘀黄型16例(16.16%)、阳虚瘀黄型9例(9.09%);(3)各证型间性别和年龄分布未见统计学差异(P>0.05);(4)80例慢加急(亚急)性肝衰竭中,不同临床分期的证型分布有统计学差异(P<0.05),其中早期以气虚瘀黄型(43.6%)为主,中期以瘀热发黄型(27.3%)和湿热发黄型(22.7%)为主,晚期以阴虚瘀黄型(27.8%)为主;(5)实验室指标中,仅阴虚瘀黄型的国际标准化比值(INR)明显高于气虚瘀黄型(P<0.05);血清生化学指标胆红素、白蛋白等均与中医证型无关(P>0.05)。结论:瘀热发黄、气虚瘀黄和湿热发黄型是浙江地区CSHB的主要证型;在构成CSHB的主要人群慢加急(亚急)性肝衰竭中,早期以气虚瘀黄型为主,中期多以瘀热发黄、湿热发黄型为主,晚期以阴虚瘀黄型多见;阴虚瘀黄型患者的凝血功能明显较气虚瘀黄型差,但不能从临床常规实验室指标对证型进行明确区分。