《终末期肝病肝功能评估[1]》由会员分享，可在线阅读，更多相关《终末期肝病肝功能评估[1]（30页珍藏版）》请在金锄头文库上搜索。
1、肝硬化患者 肝脏储备功能的研究进展,上海交通大学医学院附属仁济医院 上海市消化疾病研究所,邱德凯,1964年 Child-Turcotte 肝功能分级 1973年 Child-Turcott-Pugh (CTP) 1997年 UNOS 成人(18岁)肝病严重程度分级 2000年 Mayo TIPS模型 2001年 终末期肝病模型(Model for End-stage Liver Disease，MELD) Combined MELD 2007年 Lille Model,肝功能评估的发展历史,MELD,(Model for End-stage Liver Disease) (终末期肝病模型),
2、MELD = 9.57 log e(creatine mg/dl) + 3.78 log e （积分） (bilirubin mg/dl) +11.20 log e (INR) + 6.4 3 (肝硬化病因：胆汁性或酒精性0，其余为1） (6-40 ) 若MELD积分相同则： MELD（30d内积分的差值）0表明疾病在进展； 0表明疾病处于相对平稳期或在好转。,see: http:/www.mayo.edu/int-med/gi/model/mayomodl-5-unos.htm to calculate MELD score directly,Liver Transpl,2003.9:19-
3、20,Kiran M.Banbha,Curr opi org transp 2008,13:227-233,RELATIONSHIP BETWEEN MELD AND 3-MONTH MORTALITY IN HOSPITALIZED CIRRHOTIC PATIENTS,Adapted from Wiesner RH, McDiarmid SV, Kamath PS, et al : MELD and PELD: application of survival models to liver allocation. Liver Transpl 2001;7:567-580,2002年2月27
4、日：美国器官共享网/全美器官获取和移植网(Organ Procurement and Transplantation Network, OPTN)确定MELD为选择肝移植患者的新标准,MELD score No. of patients Perioperative mortality, n (%) 8 9,1-Year 3-Year 5-Year MELD score survival (%) survival (%) survival (%),Perioperative Mortality and long-term survival after Hepatic Resection for
5、HCC,Journal Of Gastrointestinal Surgery 2005 Dec; Vol. 9 (9), pp. 1207-15,The perioperative mortality for patients with MELD score 9 was significantly greater than that for patients with MELD score 8 (0.01).,The long-term survival for patients with MELD score 9 was significantly shorter than that fo
6、r patients with MELD score 8 (0.01). .,37 0 (0),45 13 (29),8 89 63 51,9 46 34 23,Outcome post-transplant dependent on MELD between listing and transplant,MELD +1 MELD +1 P-value 90 day survival (%) 180 day survival (%) 1 year survival (%) 2 year survival (%) 3 year survival (%),Transpl Int, 2006 Dec
7、; Vol. 19 (12), pp. 988-94;,95.3 90.4 0.0001,94.9 84.7 0.0001,91.9 77.8 0.0001,88.1 72.1 0.0001,88.1 72.1 0.0001,Change in MELD score whilst on the transplant waiting list has a significant effect on survival post-transplant,MELD的局限性,没有包括任何临床症状的判断，也没有考虑到患者的生 活质量,对于合并有严重的门脉高压、顽固性腹水以及肝性脑病的病人，在实行器官分配原则
8、时，应当增加除MELD之外的其它附加条件,Four clinical stages of cirrhosis,stage 1 :patients without varices or ascites (mortality is about 1% per year) Stage 2 : patients with varices but without ascites or bleeding (mortality rate of about 4% per year ) Stage 3 :patients have ascites with or without esophageal varice
9、s that have never bled (mortality rate while remaining in this stage is 20% per year ) Stage 4 :with portal hypertensive GI bleeding with or without ascites (1-year mortality rate of 57% ),compensated cirrhosis,decompensated cirrhosis,De Franchis R. J Hepatol 2005; 43:167176.,HVPG,patients with an H
10、VPG 10mmHg had a 90% probability of not developing clinical decompensation during a follow-up period of up to 4 years In compensated cirrhosis, markers of portal hypertension such as varices, splenomegaly, platelet count, gamma globulin level and HVPG were significant mortality predictors,DAmico G,
11、J Hepatol 2006;44:217231.,MELD 联合血清钠水平(SNa),MELD-AS MELD-Na iMELD,MELD-AS,MELD-AS = MELD + 4.53 X 0,1*+ 4.46 X 0,1*,HEPATOLOGY. 2004 Oct; 40:802- 810,*If sodium 135mmol/L,=1;otherwise =0,*If persistent ascites,=1;otherwise =0,HEPATOLOGY. 2004 Oct; 40:802- 810,MELD-AS,CTP MELD MELD-AS ALL MELD MELD21
12、,0.789 0.83 0.874,0.696 0.687 0.790,0.586 0.773 0.758,Predictors of 180-day Cirrhotic Patient Mortality,MELD-AS may improve predictive accuracy, especially at lower MELD scores,Association between serum sodium levels and severity of ascites and complications of cirrhosis,血清钠 135mmol/L，,Hepatology 20
13、06 Dec; Vol. 44 (6), pp. 1535-42.,发生腹水的概率要比血钠水平正常的患者高；,血清钠 130mmol/L，,更容易出现肝性脑病、自发性细菌性腹膜炎、 肝肾综合征。,MELD-Na,MELD-Na = MELD +1.0x(140- Na) 0.025 MELD (140 Na) . Use of the MEL-DNa score may reduce mortality among patients on the waiting list. The difference between the MELD score and the MELD-Na score
14、was often large enough to make a real difference in the probability of receiving a liver transplant and averting death,W.Ray Kim et al.N Eng J Med 2008;359:1018-26,W.Ray Kim et al.N Eng J Med 2008;359:1018-26,the expected number of transplantations : 67 (58.4% 18.5%)+ 43 (70.4% 58.4%)=32 Thus, 7% of
15、 deaths (32 of 477) that occurred within 3 months after registration on the waiting list might have been prevented,Prevalence of Ascites, Severity of Liver Failure, Renal Function, and Mortality According to Hyponatremia Status in Patients Not Transplanted Within 3 Months,No hyponatremia Hyponatremia Value
