肝硬化的诊断、分期及治疗原则
DOI: 10.3969/j.issn.1001-5256.2021.01.004
作者贡献声明:王宇负责写作设计、搜集资料并分析,撰写论文;王民、张冠华、何福亮及欧晓娟参与搜集资料、修改论文;贾继东负责写作设计、思路指导及论文修改并最后定稿。
Clinical diagnosis, staging, and therapeutic principles of liver cirrhosis
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摘要: 近年来,随着对肝硬化的发病机制、病理生理、治疗和预后研究不断深入,国内外学者在诊断分期和治疗观念上有了很大变化。除了常用的代偿期和失代偿期二分法外,还可以根据腹水、食管胃静脉曲张出血及严重感染等表现分为五期。新的分期方法突出了不同阶段疾病的特点,为治疗提供了目标和依据。目前,病因治疗、针对关键发病机制和主要并发症的治疗,以及营养支持、运动指导及戒烟酒、改善口腔卫生等改善生活方式的综合治疗,是延缓疾病进展、改善预后的关键,而肝移植仍是治疗终末期肝硬化的最有效手段。Abstract: With in-depth studies on the pathogenesis, pathophysiology, treatment, and prognosis of liver cirrhosis in recent years, there have been great changes in staging and treatment concepts among scholars in China and globally. Besides the traditional staging system of compensated and decompensated liver cirrhosis, liver cirrhosis can be divided into five stages based on ascites, variceal bleeding, and severe infection, which highlights the features of this disease in different disease stages and this provides potential targets and basis for treatment. At present, the comprehensive management of liver cirrhosis, including etiological treatment, treatment targeting key pathogenesis and major complications, nutritional support, exercise guidance, and lifestyle adjustment (smoking cessation, alcohol withdrawal, and improvement of oral hygiene), is the key to delaying disease progression and improving prognosis, and liver transplantation remains the most effective approach for end-stage liver cirrhosis.
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Key words:
- Liver Cirrhosis /
- Diagnosis /
- Staging /
- Therapeutics
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[1] TSOCHATZIS EA, BOSCH J, BURROUGHS AK. Liver cirrhosis[J]. Lancet, 2014, 383(9930): 1749-1761. DOI: 10.1016/S0140-6736(14)60121-5 [2] Chinese Society of Hepatology, Chinese Medical Association. Chinese guidelines on the management of liver cirrhosis[J]. J Clin Hepatol, 2019, 35(11): 2408-2425.(in Chinese) DOI: 10.3969/j.issn.1001-5256.2019.11.006中华医学会肝病学分会. 肝硬化诊治指南[J]. 临床肝胆病杂志, 2019, 35(11): 2408-2425. DOI: 10.3969/j.issn.1001-5256.2019.11.006 [3] European Association for the Study of the Liver. EASL clinical practice guidelines for the management of patients with decompensated cirrhosis[J]. J Hepatol, 2018, 69(2): 406-460. DOI: 10.1016/j.jhep.2018.03.024 [4] Chinese Society of Infectious Disease, Chinese Medical Association; Chinese Society of Hepatology, Chinese Medical Association. Guidelines for the prevention and treatment of chronic hepatitis B(version 2019)[J]. J Clin Hepatol, 2019, 35(12): 2648-2669. (in Chinese) DOI: 10.3969/j.issn.1001-5256.2019.12.007中华医学会感染病学分会, 中华医学会肝病学分会. 慢性乙型肝炎防治指南(2019年版)[J]. 临床肝胆病杂志, 2019, 35(12): 2648-2669. DOI: 10.3969/j.issn.1001-5256.2019.12.007 [5] Chinese Society of Hepatology and Chinese Society of Infectious Diseases, Chinese Medical Association. The guideline of prevention and treatment for hepatitis C (2019 version) [J]. J Clin Hepatol, 2019, 35(12): 2670-2686. (in Chinese) DOI: 10.3969/j.issn.1001-5256.2019.12.008中华医学会肝病学分会, 中华医学会感染病学分会. 丙型肝炎防治指南(2019年版)[J]. 临床肝胆病杂志, 2019, 35(12): 2670-2686. DOI: 10.3969/j.issn.1001-5256.2019.12.008 [6] Chinese Foundation for Hepatitis Prevention and Control; Chinese Society of Infectious Disease and Chinese Society of Hepatology, Chinese Medical Association; Liver Disease Committee of Chinese Research Hospital Association. Consensus on clinical application of transient elastography detecting liver fibrosis: A 2018 update[J]. Chin J Hepatol, 2019, 27(3): 182-191. (in Chinese)中国肝炎防治基金会, 中华医学会感染病学分会, 中华医学会肝病学分会和中国研究型医院学会肝病专业委员会. 瞬时弹性成像技术诊断肝纤维化专家共识(2018年更新版)[J]. 中华肝脏病杂志, 2019, 27(3): 182-191. [7] WANG Y, WANG M, OU XJ, et al. Diagnosis and treatment of portal hypertension caused by rare diseases[J]. J Clin Hepatol, 2019, 35(1): 29-32. (in Chinese) DOI: 10.3969/j.issn.1001-5256.2019.01.005王宇, 王民, 欧晓娟, 等. 少见、罕见疾病所致门静脉高压症的诊断与治疗[J]. 临床肝胆病杂志, 2019, 35(1): 29-32. DOI: 10.3969/j.issn.1001-5256.2019.01.005 [8] FLEMING KM, AITHAL GP, CARD TR, et al. All-cause mortality in people with cirrhosis compared with the general population: A population-based cohort study[J]. Liver Int, 2012, 32(1): 79-84. DOI: 10.1111/j.1478-3231.2011.02517.x [9] D'AMICO G, GARCIA-TSAO G, PAGLIARO L. Natural history and prognostic indicators of survival in cirrhosis: A systematic review of 118 studies[J]. J Hepatol, 2006, 44(1): 217-231. DOI: 10.1016/j.jhep.2005.10.013 [10] ARVANITI V, D'AMICO G, FEDE G, et al. Infections in patients with cirrhosis increase mortality four-fold and should be used in determining prognosis[J]. Gastroenterology, 2010, 139(4): 1246-1256, 1256. e1-e5. DOI: 10.1053/j.gastro.2010.06.019 [11] FEDE G, D'AMICO G, ARVANITI V, et al. Renal failure and cirrhosis: A systematic review of mortality and prognosis[J]. J Hepatol, 2012, 56(4): 810-818. DOI: 10.1016/j.jhep.2011.10.016 [12] D'AMICO G, MORABITO A, D'AMICO M, et al. New concepts on the clinical course and stratification of compensated and decompensated cirrhosis[J]. Hepatol Int, 2018, 12(Suppl 1): 34-43. http://europepmc.org/abstract/MED/28681347 [13] D'AMICO G, MORABITO A, D'AMICO M, et al. Clinical states of cirrhosis and competing risks[J]. J Hepatol, 2018, 68(3): 563-576. DOI: 10.1016/j.jhep.2017.10.020 [14] KIM TY, LEE JG, SOHN JH, et al. Hepatic venous pressure gradient predicts long-term mortality in patients with decompensated cirrhosis[J]. Yonsei Med J, 2016, 57(1): 138-145. DOI: 10.3349/ymj.2016.57.1.138 [15] GARCIA-TSAO G, ABRALDES JG, BERZIGOTTI A, et al. Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases[J]. Hepatology, 2017, 65(1): 310-335. DOI: 10.1002/hep.28906 [16] SMITH A, BAUMGARTNER K, BOSITIS C. Cirrhosis: Diagnosis and management[J]. Am Fam Physician, 2019, 100(12): 759-770. [17] WONG VW, CHIM AM, WONG GL, et al. Performance of the new MELD-Na score in predicting 3-month and 1-year mortality in Chinese patients with chronic hepatitis B[J]. Liver Transpl, 2007, 13(9): 1228-1235. DOI: 10.1002/lt.21222 [18] LIAW YF, SUNG JJ, CHOW WC, et al. Lamivudine for patients with chronic hepatitis B and advanced liver disease[J]. N Engl J Med, 2004, 351(15): 1521-1531. DOI: 10.1056/NEJMoa033364 [19] GENTILE I, SCOTTO R, COPPOLA C, et al. Treatment with direct-acting antivirals improves the clinical outcome in patients with HCV-related decompensated cirrhosis: Results from an Italian real-life cohort (Liver Network Activity-LINA cohort)[J]. Hepatol Int, 2019, 13(1): 66-74. DOI: 10.1007/s12072-018-9914-6 [20] HARMS MH, van BUUREN HR, CORPECHOT C, et al. Ursodeoxycholic acid therapy and liver transplant-free survival in patients with primary biliary cholangitis[J]. J Hepatol, 2019, 71(2): 357-365. DOI: 10.1016/j.jhep.2019.04.001 [21] LI YN, MA H, ZHOU L, et al. Autoimmune hepatitis-related cirrhosis: Clinical features and effectiveness of immunosuppressive treatment in Chinese patients[J]. Chin Med J (Engl), 2016, 129(20): 2434-2440. DOI: 10.4103/0366-6999.191760 [22] YANG J, GE K, CHEN L, et al. The efficacy comparison of carvedilol plus endoscopic variceal ligation and traditional, nonselective β-blockers plus endoscopic variceal ligation in cirrhosis patients for the prevention of variceal rebleeding: A meta-analysis[J]. Eur J Gastroenterol Hepatol, 2019, 31(12): 1518-1526. DOI: 10.1097/MEG.0000000000001442 [23] MOHANTY A, TATE JP, GARCIA-TSAO G. Statins are associated with a decreased risk of decompensation and death in veterans with hepatitis C-related compensated cirrhosis[J]. Gastroenterology, 2016, 150(2): 430-440. e1. DOI: 10.1053/j.gastro.2015.10.007 [24] BOSCH J, GRACIA-SANCHO J, ABRALDES JG. Cirrhosis as new indication for statins[J]. Gut, 2020, 69(5): 953-962. DOI: 10.1136/gutjnl-2019-318237 [25] LI S, ZHANG C, LIN LL, et al. Early-TIPS versus current standard therapy for acute variceal bleeding in cirrhosis patients: A systemic review with meta-analysis[J]. Front Pharmacol, 2020, 11: 603. DOI: 10.3389/fphar.2020.00603 [26] SONG T, RÖSSLE M, HE F, et al. Transjugular intrahepatic portosystemic shunt for hepatorenal syndrome: A systematic review and meta-analysis[J]. Dig Liver Dis, 2018, 50(4): 323-330. DOI: 10.1016/j.dld.2018.01.123 [27] BEST LM, FREEMAN SC, SUTTON AJ, et al. Treatment for hepatorenal syndrome in people with decompensated liver cirrhosis: A network meta-analysis[J]. Cochrane Database Syst Rev, 2019, 9: CD013103. http://www.researchgate.net/publication/327452682_Treatment_for_hepatorenal_syndrome_in_people_with_decompensated_liver_cirrhosis_A_network_meta-analysis [28] SRIDHARAN K, SIVARAMAKRISHNAN G. Vasoactive agents for the management of variceal bleeding: A mixed treatment comparison network meta-analysis and trial sequential analysis of randomized clinical trials[J]. Drug Res (Stuttg), 2019, 69(9): 487-495. DOI: 10.1055/a-0846-3071 [29] GE PS, RUNYON BA. Treatment of patients with cirrhosis[J]. N Engl J Med, 2016, 375(8): 767-777. DOI: 10.1056/NEJMra1504367 [30] KROWKA MJ, FALLON MB, KAWUT SM, et al. International liver transplant society practice guidelines: Diagnosis and management of hepatopulmonary syndrome and portopulmonary hypertension[J]. Transplantation, 2016, 100(7): 1440-1452. DOI: 10.1097/TP.0000000000001229 [31] XU X, GUO X, DE STEFANO V, et al. Nonselective beta-blockers and development of portal vein thrombosis in liver cirrhosis: A systematic review and meta-analysis[J]. Hepatol Int, 2019, 13(4): 468-481. DOI: 10.1007/s12072-019-09951-6 [32] ZHANG Y, XU BY, WANG XB, et al. Prevalence and clinical significance of portal vein thrombosis in patients with cirrhosis and acute decompensation[J]. Clin Gastroenterol Hepatol, 2020, 18(11): 2564-2572. e1. DOI: 10.1016/j.cgh.2020.02.037 [33] CERINI F, GONZALEZ JM, TORRES F, et al. Impact of anticoagulation on upper-gastrointestinal bleeding in cirrhosis. A retrospective multicenter study[J]. Hepatology, 2015, 62(2): 575-583. DOI: 10.1002/hep.27783 [34] ZANETTO A, RODRIGUEZ-KASTRO KI, GERMANI G, et al. Mortality in liver transplant recipients with portal vein thrombosis - an updated meta-analysis[J]. Transpl Int, 2018, 31(12): 1318-1329. DOI: 10.1111/tri.13353 [35] INTAGLIATA NM, CALDWELL SH, TRIPODI A. Diagnosis, development, and treatment of portal vein thrombosis in patients with and without cirrhosis[J]. Gastroenterology, 2019, 156(6): 1582-1599. e1. DOI: 10.1053/j.gastro.2019.01.265 [36] PETTINARI I, VUKOTIC R, STEFANESCU H, et al. Clinical impact and safety of anticoagulants for portal vein thrombosis in cirrhosis[J]. Am J Gastroenterol, 2019, 114(2): 258-266. DOI: 10.1038/s41395-018-0421-0 [37] LOFFREDO L, PASTORI D, FARCOMENI A, et al. Effects of anticoagulants in patients with cirrhosis and portal vein thrombosis: A systematic review and Meta-analysis[J]. Gastroenterology, 2017, 153(2): 480-487. e1. DOI: 10.1053/j.gastro.2017.04.042 [38] NORONHA FERREIRA C, REIS D, CORTEZ-PINTO H, et al. Anticoagulation in cirrhosis and portal vein thrombosis is safe and improves prognosis in advanced cirrhosis[J]. Dig Dis Sci, 2019, 64(9): 2671-2683. DOI: 10.1007/s10620-019-05572-z [39] PONZIANI FR, ZOCCO MA, CERRITO L, et al. Bacterial translocation in patients with liver cirrhosis: Physiology, clinical consequences, and practical implications[J]. Expert Rev Gastroenterol Hepatol, 2018, 12(7): 641-656. http://europepmc.org/abstract/MED/29806487 [40] SALEHI S, TRANAH TH, LIM S, et al. Rifaximin reduces the incidence of spontaneous bacterial peritonitis, variceal bleeding and all-cause admissions in patients on the liver transplant waiting list[J]. Aliment Pharmacol Ther, 2019, 50(4): 435-441. DOI: 10.1111/apt.15326 [41] KANG SH, LEE YB, LEE JH, et al. Rifaximin treatment is associated with reduced risk of cirrhotic complications and prolonged overall survival in patients experiencing hepatic encephalopathy[J]. Aliment Pharmacol Ther, 2017, 46(9): 845-855. DOI: 10.1111/apt.14275 [42] BUNCHORNTAVAKUL C, REDDY KR. Review article: Malnutrition/sarcopenia and frailty in patients with cirrhosis[J]. Aliment Pharmacol Ther, 2020, 51(1): 64-77. DOI: 10.1111/apt.15571 [43] TANDON P, BERZIGOTTI A. Management of lifestyle factors in individuals with cirrhosis: A pragmatic review[J]. Semin Liver Dis, 2020, 40(1): 20-28. DOI: 10.1055/s-0039-1696639
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