Early warning of acute-on-chronic liver failure and advantages of integrated treatment of Traditional Chinese and Western Medicine
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摘要: 慢加急性肝衰竭起病急骤，病情凶险，病死率高。对于慢加急性肝衰竭强调早期预警、动态评估病情、预后评价等全病程管理。诊疗应重视去除病因、防治并发症、器官支持和中医药干预。本文评述慢加急性肝衰竭的定义、发病机制、预警、预后评分和中西医结合治疗优势，旨在为疾病的早期识别、预后判断和中西医结合临床治疗提供借鉴。Abstract: Acute-on-chronic liver failure(ACLF) is characterized by acute onset, dangerous condition and high mortality. Early warning, dynamic evaluation and prognosis evaluation are emphasized in the management of the whole course of ACLF. The diagnosis and treatment should pay attention to the elimination of etiology, prevention and treatment of complications, organ support and intervention of Traditional Chinese Medicine. The definition, pathogenesis, early warning, prognostic score and progress of integrated Traditional Chinese and Western Medicine in the treatment of ACLF were reviewed. The purpose of this study is to provide reference for early identification, prognosis judgement and clinical treatment of integrated Traditional Chinese and Western Medicine of ACLF.
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表 1 ACLF患者预警和预后评分表
评分表 观察指标 适用人群 优点 缺点 ACLF预警评分 年龄、TBIL、PTA和HBV DNA拷贝数 HBV相关急性肝损伤 指标客观，纳入病毒复制指标 单中心建立的模型，临床价值需要验证 AD-ACLF预警模型 HBV再激活，高HBV-DNA载量，乙型肝炎病毒叠加感染，细菌感染，TBIL、INR、NLR 急性失代偿期肝硬化 多中心大样本模型，包含失代偿确切原因信息的模型 指标复杂，阳性预测值较低 COSSH-onset- ACLF ALT、TBIL、INR和血清铁蛋白 急性失代偿期肝硬化及严重肝损伤 采用COSSH-ACLF标准，在HBV患者中预测新发ACLF 不适用于EASL-ACLF人群 CTP HE、腹水、TBIL、ALB和PTA 肝硬化及肝衰竭 数据简单易得 主观性强, 易受临床因素干扰, 无肾功能指标 MELD、MELD- Na TBIL、Cr、INR、病因(Na) 肝硬化、急性肝功能失代偿、肝衰竭 指标客观、加入病因和肾功能指标 未纳入SI评价指标 CLIF-C ACLF 年龄、CLIF-C OF和WBC 重症肝硬化、肝衰竭 评估指标全面、较SOFA评分更简单 适用于酒精性肝病和丙型肝炎的西方人群 AARC HE、TBIL、INR、Cr和乳酸 ACLF 基于东方病因纳入人群，HBV人群占比多, 计算简单、乳酸反映肝脏代谢 应用时间短，需要进一步验证 COSSH-ACLFⅡs 年龄、HE、TBIL、INR、BUN和中性粒细胞计数 HBV-ACLF 器官衰竭分级更加简单准确 对于其他病因的预后价值不明确 NLR NLR HBV-ACLF 指标单一，计算简便 对其他病因的ACLF患者预后价值不明确，其准确性需要进一步验证 列线图模型 年龄、TBIL、Alb、INR和HE HBV-ACLF 符合东方标准的HBV-ACLF患者个体化预后评价 对于其他病因的预后价值不明确 免疫-临床模型 年龄、TBIL、CXCL2和IL-8 HBV-ACLF 纳入了免疫和炎症指标 样本数量少，需要外部队列验证 三代谢模型 哌替酯、N-乙酰-天门冬氨酸-谷氨酸、尿苷丙酸联合年龄、INR、Cr、Na、ALB、NLR和HE HBV-ACLF 代谢生物标志物和临床指标相结合，预后更加准确 需要进一步验证代谢物的预后价值 P5评分 纤溶酶原水平、HE、年龄、INR和TBIL HBV-ACLF 应用蛋白质组学鉴定生物标志物 需要进一步探究其他备选生物标志物 脂质代谢物及肠道微生物 3-苯丙酸、4-羟基苯甲酸酯、5-羟基吲哚乙酸酯、胆碱、甘油三酯、硫酸邻甲酚、三甲胺N-氧化物、芳香化合物、次级或硫酸盐胆汁酸和苯甲酸盐 肝硬化、肝衰竭 反映了患者脂质代谢物及肠道微生物特征 适用于酒精性肝病和丙型肝炎的西方人群 ABILI 年龄、TBIL、INR、乳酸脱氢酶和可溶性白介素2受体 HBV-ACLF 针对细菌感染患者的预后模型 需要外部队列验证 
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