第七章 乙型肝炎重症化和乙型重型肝炎(肝衰竭)的临床表现、实验室检查及辅助检查

内容提要

1.肝衰竭是多病因引起的严重肝损害，使肝功能发生严重障碍或失代偿，出现以凝血机制障碍和黄疸、肝性脑病、腹水等为主要表现的一组临床症候群。

2.中国《肝衰竭诊治指南（2018年版）》将肝衰竭分为：急性肝衰竭、亚急性肝衰竭、慢加急性（亚急性）肝衰竭和慢性肝衰竭。

3.显著的肝细胞坏死是乙型肝炎重症化的病理基础，表现为广泛的多灶状坏死、融合性坏死、桥接坏死、亚大块坏死和大块坏死。

4.实验室检查指标可以及时、敏感地反映乙型肝炎重症化和重型肝炎病程中肝脏的病理变化和功能状况，为临床分型评分和疗效的评估提供客观翔实的参考数据，其中以凝血酶原活动度、国际标准化比值、总胆红素上升的速度及幅度等较为重要。

5.乙型肝炎重症化和重型肝炎与病毒和宿主因素的相互作用有关，检测HBV DNA定量、基因型、准种和HBV变异等参数可为预防、控制或者减缓乙型肝炎重症化的进程提供重要理论科学依据。

6.影像学检查作为一种无创方法能够对肝脏整体和局部进行观察。应用影像学方法测量肝脏体积来评价肝脏大小和功能储备，可作为乙型肝炎重症化和重型肝炎患者诊断、手术方式选择及预后评估的一项重要指标。

7.终末期肝病模型(MELD)是第一个能客观评估肝衰竭患者是否需要行肝移植的量化方法，在MELD基础上加以改进和完善，提出MELD-Na、iMELD、MESO等模型。国内学者也发表一些新的有价值的预测模型，其中针对特殊的HBV-ACLF患者，同济预测模型(TPPM)显示出比MELD更好的预测价值。(https://www.daowen.com)

Abstract 7

1.Liver failure is defined as serious damage to the liver cause by a variety of etiologies，leading to liver function disorder or even decompensation，and clinical syndromes with coagulopathy，jaundice，hepatic encephalopathy，and ascites.

2.Chinese Guideline for the diagnosis and treatment of liver failure（2018） classifies liver failure into 4 categories：acute liver failure, subacute liver failure, chronic acute (subacute)liver failure and chronic liver failure.

3.Severehepatitis B can be indicated pathologically by apparenthepatocellular necrosis，including extensive multifocal，confluent，bridging，sub-massive or massive necrosis.

4.Laboratory tests during the course of severe exacerbation of chronichepatitis B can reflect pathological changes and liver function in a timely manner，providing objective and informative reference data for evaluation of disease severity and treatment efficacy.The important laboratory indexes are prothrombin activity，international normalized ratio，and increases in total bilirubin concentration.

5.Severehepatitis B is associated with interactions between the virus andhost factors.Detection of HBV DNA，HBV genotype，quasispecies and HBV mutation can provide important theoretical bases for the prevention，control or mitigation of the progress of severehepatitis B.

6.Noninvasive imaging modalities can be used to visualize the entire liver and parts of it.Measuring liver volume to evaluate liver size and liver reserve capacity is regarded as important index in diagnosis，surgical approach and prognostic evaluation of patients with severe exacerbation of chronichepatitis B and liver failure.

7.Model for End-Stage Liver Disease (MELD)is the first quantitative method developed to assess whether a patient with liver failure requires a liver transplant.The predictive value of the MELD modelhas been improved by the MELD-Na，iMELD，and MESO models.Several other valuable prognostic modelshave been developed.For example，for patients with HBV-ACLF，the established TPPM scoring system was found to be more predictive than MELD score.