摘要
肝衰竭的诊治热点与难点问题众多,许多问题国内外仍存在争议。西方国家对于急性肝衰竭的诊断并不取决于慢性肝病史的存在与否,而包括我国在内的亚太地区则认为慢性肝病基础是决定疾病特征的重要因素。病因治疗在急性肝衰竭治疗中至关重要,目前已证实应用N-乙酰半胱氨酸可显著改善药物性肝损伤所致急性肝衰竭的总生存率,而有学者认为长疗程N-乙酰半胱氨酸的使用并不增加患者受益;对于HBV相关急性肝衰竭抗病毒治疗适应证,除了我国指南要求HBV DNA阳性外,其他各大指南对此不作要求;HCV相关肝硬化患者采用直接抗病毒药物治疗可获得较高的持续病毒学应答率,但应充分评估各种直接抗病毒药物治疗的临床安全性及有效性。预防性使用抗生素可能对肝衰竭患者合并感染有利,但证据尚不充分;经验性抗菌治疗则应根据具体情况进行制订,并可尝试非抗生素的治疗手段来预防感染(如益生菌、胃肠动力调节剂及辛伐他汀等)。研究发现,免疫调节剂在肝衰竭治疗中发挥着重要作用,但其治疗时机、适应证、使用剂量、疗程及不同类型肝损伤的特异性和适应性等需进一步临床研究。总之,临床专家应根据本国及本地区的具体情况,立足指南和共识,灵活合理运用,深入研究,争取提高肝衰竭诊疗水平。
There are many hot and difficult points in the diagnosis and treatment of liver failure,and controversies still exist both at home and abroad. In the Western countries,the diagnosis of acute liver failure（ALF） does not depend on history of chronic liver disease. In Asian-Pacific region,including China,it is believed that the basis of chronic liver disease is an important factor determining disease characteristics. Etiological treatment is believed to be very important in the treatment of ALF. It has been confirmed that the application of NAC can significantly improve the overall survival rate of ALF induced by drug-induced liver injury. However,some scholars believe that the use of long-course NAC can not increase patients＇ benefits,which still needs further confirmation. For indications of HBV-ALF antiviral therapy,HBV DNA is not required to be positive in any guidelines except the guidelines in China. Although patients with HCV-related cirrhosis can achieve high SVR rate with DAA antiviral therapy,the clinical safety profile of various DAA treatments should be fully evaluated. Prophylactic use of antibiotics may be beneficial in patients with liver failure,but there is also an argument for lacking of evidence. Empirical antimicrobial therapy should be formulated according to the specific situation and non-antibiotic treatment can be tried to prevent infection including probiotics,gastrointestinal motility regulators,simvastatin,etc. It has been found that immunomodulators play an important role in the treatment of liver failure,but the timing,indications,dosage,course of treatment,specificity and adaptability of different liver injuries remain further clinical research. In conclusion,clinical experts should apply guidelines and consensus flexibly and rationally,and conduct in depth research based on specific situations as well as the guidelines and consensus,so as to improve the level of diagnosis and treatment of liver failure.
作者
王宇明
赵学兰
WANG Yuming;ZHAO Xuelan(The First Affiliated Hospital of Army Medical University,Chongqing 400038,China)
出处
《临床肝胆病杂志》
CAS
北大核心
2018年第9期1819-1823,共5页
Journal of Clinical Hepatology
关键词
肝功能衰竭
感染
免疫疗法
述评
liver failure
infection
immunotherapy
editorial
