进展性慢性肝病与重症肝炎患者肝移植围手术期凝血功能的变化

目的比较进展性慢性肝病及重症肝炎患者原位肝移植(OLT)围手术期凝血功能的变化。方法回顾性分析我中心2004年1月至2005年12月期间行OLT治疗进展性慢性肝病及重症肝炎患者各37例的围手术期血小板(PLT)、凝血酶原时间(PT)、活化部分凝血活酶时间(APTT)及纤维蛋白原(FIB)的变化。结果2组患者除术前PT、APTT,术后第5dPLT、FIB和术后第7dFIB的差异有统计学意义外(P<0.05),其余时段2组患者的PLT、PT、APTT及FIB间差异均无统计学意义(P>0.05),提示重症肝炎患者凝血功能损害更为严重;OLT术后,2组患者的凝血功能均逐渐恢复正常,但并非完全同步。结论进展性慢性肝病与重症肝炎患者OLT围手术期凝血功能变化显著,应注意监测及处理,但术后2组间各指标间比较差异并不明显。

进展性慢性肝病发生慢加急性肝衰竭的风险预测及分层管理

进展性慢性肝病患者因肝炎活动、急性失代偿或肝衰竭及其并发症住院,病情严重程度不一,需要分层管理。慢加急性肝衰竭(ACLF)是进展性慢性肝病患者中短期病死率最高的群体,均应在三级医院诊治。未达到ACLF的患者虽然病死率相对较低,但存在进展至ACLF的风险,一旦进展到ACLF,病死率明显增加,需进行分层管理:其中进展率极低的患者转归良好,在基层医院救治即可;而有进展至ACLF风险的高危人群,应当密切监视病情变化,及时转诊。目前尚缺乏准确评估进展至ACLF风险的预测模型,需要进一步研究新的标志物或算法。

婴儿感染丙肝后患进展性肝病风险低

一项意大利的研究显示，新生儿通过血液传播而获得的肝病毒（HCV）感染，至少在以后的35年中有一个疾病发展速度相对较慢的良性过程。所有病毒血症（veremic）病例都与Tb基因型相关，并且被认为是最具攻击性的。

进展期非酒精性脂肪性肝病的识别和临床管理路径

非酒精性脂肪性肝病(NAFLD)全球流行率达30%~40%,特别是患有2型糖尿病、肥胖和心血管疾病的患者,发生NAFLD的风险尤其高,已成为最常见的慢性肝病。NAFLD患者可进展为肝硬化、肝癌。NAFLD患者的绝对数量巨大,疾病负担重,然而在基层医疗和糖尿病管理机构中,NAFLD患者进展性肝病风险的识别仍然非常不理想。本文总结一种对NAFLD患者进行危险分层的方法,这将有助于医务工作者对NAFLD患者的管理。

社区2型糖尿病合并NAFLD患病流行率调查

目的探讨社区2型糖尿病(T2DM)患者非酒精性脂肪性肝病(NAFLD)和代偿期进展性慢性肝病(cACLD)患病情况及其影响因素。方法2021年7月~9月在邢台市5个社区调查糖尿病患者,采用现场问卷调查,记录身高、体质量、血压、血糖和血脂,使用FibroScan瞬时弹性成像仪行肝脏硬度检测(LSM)和受控衰减参数(CAP)检测。采用二元Logistic回归分析影响T2DM合并重度NAFLD的危险因素。结果本研究纳入登记在册的946例社区T2DM患者,女性占64.5%,显著多于男性(35.5%,P<0.05);合并NAFLD患者664例(70.2%),其中重度334例(50.3%),中度198例(29.8%),轻度132例(19.9%);T2DM合并cACLD者94例(9.9%),正常体质量、超重和肥胖人群cACLD患病率分别为6.1%、10.5%和17.6%;差异性分析显示,超重和肥胖、高血脂、冠心病和糖尿病病程是社区T2DM合并不同程度NAFLD的影响因素(P<0.05),超重和肥胖、高血脂和冠心病是社区T2DM合并cACLD的影响因素(P<0.05);二元Logistic回归分析显示,BMI是社区T2DM合并重度NAFLD的独立影响因素(P<0.05)。结论本组T2DM合并NAFLD患病率较高,而cACLD患病率也达到9.9%,应予以重视。

Increased intestinal permeability in pathogenesis and progress of nonalcoholic steatohepatitis in rats

AIM： To investigate whether increased intestinal permeability contributes to the pathogenesis and progress of nonalcoholic steatohepatitis by observing its dynamic change in rat models. METHODS： Rat models of nonalcoholic steatohepatitis were established by giving a fat-rich diet. The rats were sacrificed at wk 8, 12 and 16 during the study. Rats fed with normal diet were taken as control. Plasma D-lactate, plasma diarnine oxidase, serum lipids and liver transarninases were measured in blood of the femoral artery. Hepatic steatosis and inflammation were assessed by haematoxylin-eosin staining. RESULTS： A rat model of nonalcoholic steatohepatitis was established successfully. Plasma D-lactate level in model group at wk 8, 12 and 16 and diarnine oxidase level in model group at wk 12, 16 increased significantly compared with those in control group. There were notable differences of D-lactate and diarnine oxidase level in model group between wk 8 and 12 as well as between wk 12 and 16. Serum lipids, liver transaminases and liver injury also increased with disease development CONCLUSION： Increased intestinal permeability caused by intestinal bacterial overgrowth and endotoxin-induced intestinal destruction exists in rats with nonalcoholic steatohepatitis, which may partially explain the pathogenesis and progress of this disease.

社区2型糖尿病患者合并肝脏疾病的检出率及临床特征:一项基于霍州市社区人群的横断面研究

目的探讨社区2型糖尿病(T2DM)患者中非酒精性脂肪性肝病(NAFLD)、代偿期进展性慢性肝病及门静脉高压的合并症检出率及临床特征。方法为横断面研究。于2021年5至6月电话通知霍州市11个乡(镇、街道办事处)登记在册的T2DM患者参与本次社区筛查。所有研究对象进行现场体格检查(测量身高、体重、颈围、腰围、腹围、血压)。通过瞬时弹性成像技术测量受控衰减参数(CAP)和肝脏硬度(LSM)。根据CAP数值将NAFLD分为:轻度NAFLD(238 dB/m≤CAP≤258 dB/m)组、中度NAFLD(259 dB/m≤CAP≤291 dB/m)组和重度NAFLD(CAP≥292 dB/m)组。根据LSM≥10 kPa、LSM≥15 kPa分别提示患者发展为代偿期进展性慢性肝病和门静脉高压阶段。依据体重指数(BMI)将受试者分为正常体重及过低(BMI<24 kg/m2)组、超重(24 kg/m^(2)≤BMI<28 kg/m^(2))组以及肥胖(BMI≥28 kg/m^(2))组。组间比较采用方差分析或χ²检验。结果本研究共筛查霍州市登记在册的社区T2DM患者1191例,其中NAFLD、代偿期进展性慢性肝病、门静脉高压的加权合并症检出率分别为61.5%、6.5%、1.7%。社区T2DM患者中无NAFLD组460例、轻度NAFLD组182例、中度NAFLD组271例、重度NAFLD组278例,与无NAFLD组比较,轻、中、重度NAFLD组患者BMI、颈围、腰围、臀围以及高血压的患病率均显著增加(P<0.05)。T2DM合并NAFLD患者731例,其中正常体重及过低组179例(24.5%)、超重组382例(52.3%)、肥胖组170例(23.2%),正常体重及过低组、超重组、肥胖组加权占比分别为23.7%、51.2%、25.1%。结论社区T2DM患者有较高的NAFLD、代偿期进展性慢性肝病及门静脉高压合并症检出率。

Diagnosis of cirrhosis and portal hypertension:imaging,non-invasive markers of fibrosis and liver biopsy

The concept of‘cirrhosis’is evolving and it is now clear that compensated and decompensated cirrhosis are completely different in terms of prognosis.Furthermore,the term‘advanced chronic liver disease(ACLD)’better reflects the continuum of histological changes occurring in the liver,which continue to progress even after cirrhosis has developed,and might regress after removing the etiological factor causing the liver disease.In compensated ACLD,portal hypertension marks the progression to a stage with higher risk of clinical complication and requires an appropriate evaluation and treatment.Invasive tests to diagnose cirrhosis(liver biopsy)and portal hypertension(hepatic venous pressure gradient measurement and endoscopy)remain of crucial importance in several difficult clinical scenarios,but their need can be reduced by using different non-invasive tests in standard cases.Among non-invasive tests,the accepted use,major limitations and major benefits of serum markers of fibrosis,elastography and imaging methods are summarized in the present review.