第十二章 乙型肝炎重症化和乙型重型肝炎(肝衰竭)的预后、预防和研究展望

内容提要

1.影响乙型重型肝炎患者预后的主要因素有病因(包括病毒载量、HBeAg表达、基因变异)、患者年龄、伴随疾病、总胆红素、凝血酶原活动度、血清肌酐，宿主的遗传背景与预后的关系近年受到重视。与乙型重型肝炎患者预后相关的指标包括总胆红素、总胆固醇、白蛋白和前白蛋白、肝性脑病、肾脏损害、甲胎蛋白、维生素 D 结合蛋白、血清钠水平、HBeAg表达及基因分型、血糖水平。

2.除经典的总胆红素、凝血酶原活动度、肝性脑病、肌酐水平和AFP为重型肝炎预后的评价指标外，患者临床体征、多项生化指标、凝血因子都对预后评估有参考价值。细胞凋亡、肝脏再生和免疫学指标对预后的评估价值正在积极研究中。预后评估分析系统有MELD、MELD-Na、iMELD、英国皇家学院标准和Child-Turcotte-Pugh评分。

3.乙型重型肝炎的主要死因有感染与全身炎症反应综合征、上消化道出血、肝性脑病、急性肾损伤。远期预后除与上述因素有关外，还与并发症的发生、类型和严重程度有关。

4.乙型肝炎重症化的预防应从无症状感染者的管理和保健做起，对于CHB患者，严密观察病情、充足的休息、合理的营养、良好的护理和心理指导、预防和去除重症化诱因、正确处理伴发疾病、合理的抗病毒和综合治疗有助于预防乙型肝炎重症化。对已发生重型肝炎者应积极预防和治疗并发症。

5.乙型肝炎重症化的未来展望主要内容：阐明宿主遗传背景，病毒基因型、变异、转录调控，宿主免疫变化与重型肝炎发生的关系；研究乙型重型肝炎血流动力学改变的机制及干预措施；完善乙型肝炎重症化的预测因素和评估模型；探讨最佳的抗病毒治疗方案，确定不同类型人工肝支持疗法的适应对象、治疗时机、疗程及成本效益比；积极开展乙型重型肝炎的细胞治疗研究。(https://www.daowen.com)

Abstract 12

1.Factors affecting the prognosis of patients with severehepatitis B include those related to the virus (including viral load，HBeAg expression，and gene mutation)，patient age，co-morbidity，TBil，PTA，serum Cr，and thehost genetic background.Indicators associated with the prognosis of patients with severehepatitis B include TBil，total cholesterol，albumin and prealbumin，hepatic encephalopathy，kidney damage，alpha-fetoprotein and vitamin D binding protein，blood sodium level，virus HBeAg expression and genotype，and blood glucose.

2.In addition to TBil，PTA，hepatic encephalopathy，Cr level and AFP as indicators for prognosis of severehepatitis，clinical signs and symptoms，biochemical parameters，and coagulation factors are all valuable in assessment of prognosis.The roles of cell apoptosis，liver regeneration and immunological parameters in assessing patient prognosis are under study.Prognosis assessment analysis systems include MELD，MELD-Na，iMELD，KCC and CTP.

3.The leading causes of death in patients with severehepatitis B include infection and SIRS，upper gastrointestinal bleeding，hepatic encephalopathy，and acute renal injury.Long-term prognosis is also closely related to treatment and complications.

4.Prevention of severehepatitis B should be started in asymptomatic patients.Close observation，sufficient rest，proper nutrition，good care and psychological guidance for CHB patients，preventing and removing exacerbating factors，correctly treating concomitant diseases，reasonable antiviral and comprehensive treatment mayhelp to prevent severehepatitis B.Active prevention and treatment of complications canhelp patients who alreadyhave severehepatitis B.

5.Future studies of severehepatitis B include assessments ofhost genetic background；virus genotype,variation and transcriptional regulation；the relationship betweenhost immune change and severehepatitis B；the mechanism underlying changes inhemodynamics and intervention measures；prediction and evaluation models；optimal antiviral treatment；determining the type，timing and cost-benefit ratio of artificial liver support therapy；liver transplantation and cell therapy.