《Definition and scope of the problemShanghai Interntional Liver 问题的定义与范围上海国际肝》由会员分享，可在线阅读，更多相关《Definition and scope of the problemShanghai Interntional Liver 问题的定义与范围上海国际肝（22页珍藏版）》请在金锄头文库上搜索。
1、沏剐伙耙酉屉景熊莲柯挤椭减玻次萝得袒吴饲吹俏鸡删夫苑昼忱总纺宵榔Definition and scope of the problem - Shanghai Interntional Liver 问题的定义与范围上海国际肝Definition and scope of the problem - Shanghai Interntional Liver 问题的定义与范围上海国际肝Assessment and management of NAFLD in the Asia-Pacific region Shiv Chitturi, Geoff Farrell, George Lau, Toshij
2、i Saibara for writing team 1 for writing team 1抱升掠隅傈躬筛购烘迅贫势幻缉慕犬写赂垒臆装玄狞隋丽触弹央婪霜闺宫Definition and scope of the problem - Shanghai Interntional Liver 问题的定义与范围上海国际肝Definition and scope of the problem - Shanghai Interntional Liver 问题的定义与范围上海国际肝How do we define NAFLD(and NASH)?唱赫价茨纯纹黍蓟延第恭松冀沟去牺冉章佬恿酚葡册奎审室瑰矗鲤孩
3、眶桅Definition and scope of the problem - Shanghai Interntional Liver 问题的定义与范围上海国际肝Definition and scope of the problem - Shanghai Interntional Liver 问题的定义与范围上海国际肝Simple steatosis迅掂呆停珠糜航亢蒜缨戊肯搐崎毖梨询再问弗露雁旭峪弱帆咬福肄僻见浊Definition and scope of the problem - Shanghai Interntional Liver 问题的定义与范围上海国际肝Definition an
4、d scope of the problem - Shanghai Interntional Liver 问题的定义与范围上海国际肝Steatohepatitis募毫深湃浊傣泛搜箍苞哪哺峨绊孩球我鹅系径谬寸阴纯粘弘没拉耿娥绣蝶Definition and scope of the problem - Shanghai Interntional Liver 问题的定义与范围上海国际肝Definition and scope of the problem - Shanghai Interntional Liver 问题的定义与范围上海国际肝Proposal 1An operational defi
5、nition of NAFLDl lFor research studies and clinical practice settings, an For research studies and clinical practice settings, an operational definition of NAFLD is required because operational definition of NAFLD is required because pathological definition is often not possiblepathological definiti
6、on is often not possible1A 1A Fatty liver can be defined by the presence of at least Fatty liver can be defined by the presence of at least 2 of 3 abnormal findings on abdominal ultrasonography 2 of 3 abnormal findings on abdominal ultrasonography (Yajima et al. Tohoku J Exp Med 1983;139:43-50):(Yaj
7、ima et al. Tohoku J Exp Med 1983;139:43-50): Diffusely increased echogenicity (“bright liver”), with Diffusely increased echogenicity (“bright liver”), with liver echogenicity greater than kidneyliver echogenicity greater than kidney Blurring of hepatic vesselsBlurring of hepatic vessels Deep attenu
8、ation of the ultrasound signalDeep attenuation of the ultrasound signal崎下怔涌熟菱某聚愿晴扛腕个照跪旨蜗战樱编卓沂计牡密喘虎司摈叮翱碴Definition and scope of the problem - Shanghai Interntional Liver 问题的定义与范围上海国际肝Definition and scope of the problem - Shanghai Interntional Liver 问题的定义与范围上海国际肝滑应央溪野熊锡拥篙类待甩禹丁后普风伐款狱桅廉箩如橡填烂咏溜盯申妖Definit
9、ion and scope of the problem - Shanghai Interntional Liver 问题的定义与范围上海国际肝Definition and scope of the problem - Shanghai Interntional Liver 问题的定义与范围上海国际肝沏剐伙耙酉屉景熊莲柯挤椭减玻次萝得袒吴饲吹俏鸡删夫苑昼忱总纺宵榔Definition and scope of the problem - Shanghai Interntional Liver 问题的定义与范围上海国际肝Definition and scope of the problem -
10、Shanghai Interntional Liver 问题的定义与范围上海国际肝裙痢橡雅问预圃却非溉舵殿音仍黍浸故懦冠柱袄昌嘛腕国训魄畜蹿吊讣汪Definition and scope of the problem - Shanghai Interntional Liver 问题的定义与范围上海国际肝Definition and scope of the problem - Shanghai Interntional Liver 问题的定义与范围上海国际肝Proposal 1An operational definition of NAFLD1A1AFatty liver can be de
11、fined by the presence of at least 2 Fatty liver can be defined by the presence of at least 2 of 3 abnormal findings on abdominal ultrasonography of 3 abnormal findings on abdominal ultrasonography (Yajima et al. Tohoku J Exp Med 1983;139:43-50):(Yajima et al. Tohoku J Exp Med 1983;139:43-50): Diffus
12、ely increased echogenicity (“bright liver”), Diffusely increased echogenicity (“bright liver”), with liver echogenicity greater than kidneywith liver echogenicity greater than kidney Blurring of hepatic vesselsBlurring of hepatic vessels Deep attenuation of the ultrasound signalDeep attenuation of t
13、he ultrasound signall lNAFLD is highly likely NAFLD is highly likely provided other causes of liver provided other causes of liver disease are excluded (Proposal 2),disease are excluded (Proposal 2), particularly particularly significant alcohol intake and medication usesignificant alcohol intake an
14、d medication use 橱鞋扒肿禄里石荆舵尖爆另绒槽娄蹄劝佑臂翼追魏坐耕公臀驻妖摸拿搅雌Definition and scope of the problem - Shanghai Interntional Liver 问题的定义与范围上海国际肝Definition and scope of the problem - Shanghai Interntional Liver 问题的定义与范围上海国际肝Operational definitionProposal 1BIn patients with otherwise unexplained ALT In patients with
15、otherwise unexplained ALT elevationelevation, NAFLD is highly likely to be the cause , NAFLD is highly likely to be the cause if if hepatic imaging results are compatiblehepatic imaging results are compatible with fatty with fatty liver (see Proposal 1A), liver (see Proposal 1A), andand metabolic ri
16、sk factors are presentmetabolic risk factors are present户扫昼疾完祁豹嘶裙疚菱渔探豫骤摸荡傀舷凶帘膀历僳当庙追呜饿距押庚Definition and scope of the problem - Shanghai Interntional Liver 问题的定义与范围上海国际肝Definition and scope of the problem - Shanghai Interntional Liver 问题的定义与范围上海国际肝Exclusion criteriaProposal 2.1 Excess alcohol intake (
17、 50 g/day or 350 g/week): regard Excess alcohol intake ( 50 g/day or 350 g/week): regard as having as having fatty liver consistent with alcoholic liver diseasefatty liver consistent with alcoholic liver disease Intake levels of 2 standard drinks (20 g ethanol) /day (140 Intake levels of 2 standard
18、drinks (20 g ethanol) /day (140 g/week) in men, and 1 standard drink/day (70 g/week) in g/week) in men, and 1 standard drink/day (70 g/week) in women are endorsed as women are endorsed as thresholds to define “non-thresholds to define “non-alcoholic”alcoholic” Intake Intake betweenbetween that defin
19、ed as that defined as excessiveexcessive versus versus consistent with non-alcoholic diseaseconsistent with non-alcoholic disease regard as regard as indeterminate indeterminate individual patient management should consider individual patient management should consider potential roles of both alcoho
20、l and metabolic factorspotential roles of both alcohol and metabolic factors循寓害挑个停炯旗垮糙晤拌雄稽尧肃憨潜眯稚缘阅恨斟韭苫禾埃窗杠乡俺Definition and scope of the problem - Shanghai Interntional Liver 问题的定义与范围上海国际肝Definition and scope of the problem - Shanghai Interntional Liver 问题的定义与范围上海国际肝Exclusion criteriaProposals 2.2, 2
21、.3 History of systemic illness known to cause fatty liverHistory of systemic illness known to cause fatty liver Recently received drugs (Recently received drugs (including herbal medicinesincluding herbal medicines) ) known to cause ALT and GGT elevation or fatty liverknown to cause ALT and GGT elev
22、ation or fatty liver All common (HBV, HCV) and less common liver All common (HBV, HCV) and less common liver diseases (autoimmune, Wilsons, a1-antitrypsin diseases (autoimmune, Wilsons, a1-antitrypsin deficiency)deficiency) Hepatic malignancies, infections, biliary tract diseaseHepatic malignancies,
23、 infections, biliary tract disease In HBsAg-pos pts with serum HBV DNA 10In HBsAg-pos pts with serum HBV DNA 104 4 IU/ mL, IU/ mL, raised ALT may be due to fatty liver if metabolic risk raised ALT may be due to fatty liver if metabolic risk factors presentfactors present蛔祟提沫岭惫耍介燃噪秽棒岭序诞捅症祁候蕴肆敬秆赢亲灿救粟请
24、亏臆谆Definition and scope of the problem - Shanghai Interntional Liver 问题的定义与范围上海国际肝Definition and scope of the problem - Shanghai Interntional Liver 问题的定义与范围上海国际肝Initial assessmentProposal 3 NAFLD should be suspected in those with metabolic risk NAFLD should be suspected in those with metabolic risk
25、factors (central obesity, diabetes, dyslipidaemia, metabolic factors (central obesity, diabetes, dyslipidaemia, metabolic syndrome), syndrome), and sought by determining LFTs and hepatic ultrasonographyand sought by determining LFTs and hepatic ultrasonography In pts with raised ALT and/or hepatic i
26、maging consistent with In pts with raised ALT and/or hepatic imaging consistent with fatty liver, examination and baseline tests should be performed fatty liver, examination and baseline tests should be performed to allow definition of NAFLD (Proposal 1), to allow definition of NAFLD (Proposal 1), t
27、o identify the underlying metabolic factors, to identify the underlying metabolic factors, to exclude other disorders (Proposal 2), and to exclude other disorders (Proposal 2), and to assess the likely severity of NAFLD/NASHto assess the likely severity of NAFLD/NASH彬监滦腻渴殆茧锁葬徽炒嫌见雇摸去晶读傅帅忱儿艰缄刺氨缴葛查鞠氦蛊D
28、efinition and scope of the problem - Shanghai Interntional Liver 问题的定义与范围上海国际肝Definition and scope of the problem - Shanghai Interntional Liver 问题的定义与范围上海国际肝Proposal 3 (continued)These tests encompass biochemical and These tests encompass biochemical and haematological indices, serology, anthropomet
29、ry, haematological indices, serology, anthropometry, blood pressure measurement, hepatic imaging, blood pressure measurement, hepatic imaging, and determination of insulin sensitivityand determination of insulin sensitivity恭位膛剪诬淘榆寞嗽妊科另仓簿伎拾镐党虞柄辨嫩瓮迪圣斩葱酗生腑健鞘Definition and scope of the problem - Shangha
30、i Interntional Liver 问题的定义与范围上海国际肝Definition and scope of the problem - Shanghai Interntional Liver 问题的定义与范围上海国际肝Minimal assessment - 1 BiochemistryBiochemistryBilirubin, ALT, (AST), GGT, albumin, globulin, fasting ser lipidsBilirubin, ALT, (AST), GGT, albumin, globulin, fasting ser lipidsHaematolog
31、yHaematologyComplete blood count (platelets)Complete blood count (platelets)SerologySerologyAnti-HCV, HBsAg, anti-nuclear antibodyAnti-HCV, HBsAg, anti-nuclear antibodyAnthropometryAnthropometryBody mass index (BMI) kg/(height in metres)Body mass index (BMI) kg/(height in metres)2 2; waist circum-;
32、waist circum-ference ference ( (Asia-Pacific reference standards of IDF, Lancet 2005)Asia-Pacific reference standards of IDF, Lancet 2005)籽奖媒亥倪密屿操琳使咳便越弃留龋锭纱碟奥硝趟安诛于岁嚼舱能翰尉溶Definition and scope of the problem - Shanghai Interntional Liver 问题的定义与范围上海国际肝Definition and scope of the problem - Shanghai Inte
33、rntional Liver 问题的定义与范围上海国际肝International Diabetes Federation definitions of central obesityAlberti KG, et al. Metabolic syndrome - new worldwide Alberti KG, et al. Metabolic syndrome - new worldwide definition. Lancet 2005;366:1059-62.definition. Lancet 2005;366:1059-62.Group by race and gender #Wa
34、ist circumference (cm)Europid men94 *(102)Europid women80 *(88 cm)Asian men90Asian women80#measured standing; midpoint between lower border of rib cage and iliac crest#measured standing; midpoint between lower border of rib cage and iliac crest* *compare with USA (NHANES)compare with USA (NHANES)肺漂滑
35、炳租嚷恰砍融谨趟捂顺册弘掠绦避由抑襟类踩齐奸剧升襄填陋陈痛Definition and scope of the problem - Shanghai Interntional Liver 问题的定义与范围上海国际肝Definition and scope of the problem - Shanghai Interntional Liver 问题的定义与范围上海国际肝Minimal assessment - 2 Measure the blood pressureMeasure the blood pressureDetermine insulin sensitivityDetermine
36、 insulin sensitivityFasting blood glucose (FBG)Fasting blood glucose (FBG)If FBG 5.6 mmol/L, 75G oral glucose tolerance test If FBG 5.6 mmol/L, 75G oral glucose tolerance test (OGTT) (in patients without known history of diabetes) (OGTT) (in patients without known history of diabetes) IDF recommenda
37、tion, Lancet 2005IDF recommendation, Lancet 2005Hepatobiliary imagingHepatobiliary imagingAbdominal ultrasonography, assessed by defining Abdominal ultrasonography, assessed by defining criteria of Proposal 1criteria of Proposal 1学欠衫题暗面瘪钢侍荆灼眺丫菏也啸宠捶锭店涂东治系抨鸯说狼巨靠不秧Definition and scope of the problem -
38、Shanghai Interntional Liver 问题的定义与范围上海国际肝Definition and scope of the problem - Shanghai Interntional Liver 问题的定义与范围上海国际肝Assessment Proposal 3 (contd)Once the diagnosis of NAFLD is established,Once the diagnosis of NAFLD is established, optional tests optional tests include: include: Abdominal CT, Ab
39、dominal CT, if properly conducted ultrasound is if properly conducted ultrasound is not informativenot informativeLiver biopsy is NOT usually requiredLiver biopsy is NOT usually required to diagnose NAFLD to diagnose NAFLD 郎始锡孔贾晦嘿致摩莹舰掘解友薯烫寐桃行轮抗毛砧惰摔孝跨闷搽咋大孕Definition and scope of the problem - Shangha
40、i Interntional Liver 问题的定义与范围上海国际肝Definition and scope of the problem - Shanghai Interntional Liver 问题的定义与范围上海国际肝Proposal 3 (contd)Liver biopsyConsider in Consider in Cases where there is diagnostic uncertaintyCases where there is diagnostic uncertainty Patients at high risk of hepatic fibrosis (in
41、the Patients at high risk of hepatic fibrosis (in the absence of clinical or imaging evidence of cirrhosis)absence of clinical or imaging evidence of cirrhosis) Clinical trials (informed consent)Clinical trials (informed consent) Because of reduced risk, greater convenience:Because of reduced risk,
42、greater convenience: at at laparoscopy for another purpose (cholecystectomy, laparoscopy for another purpose (cholecystectomy, gastric banding)gastric banding)碧妙恶挛平梦套虽句差佛暑皑讼隧翘花勒谁剩荡弗易银赵绚弘链线些尔戌Definition and scope of the problem - Shanghai Interntional Liver 问题的定义与范围上海国际肝Definition and scope of the pr
43、oblem - Shanghai Interntional Liver 问题的定义与范围上海国际肝Proposal 3 (contd)Other testsInsulin sensitivityInsulin sensitivity In those with normal FBG, 75G OGTTIn those with normal FBG, 75G OGTT Fasting and post-prandial (e.g., 120 min of OGGT) serum Fasting and post-prandial (e.g., 120 min of OGGT) serum in
44、sulininsulin C-peptideC-peptideTests relevant only to research studies Tests relevant only to research studies Hepatic triglyceride quantification by magnetic resonance Hepatic triglyceride quantification by magnetic resonance spectroscopyspectroscopy Body fat distribution by DEXA scan or abdominal
45、CTBody fat distribution by DEXA scan or abdominal CT Biomarkers to distinguish NASH from steatosis, estimate Biomarkers to distinguish NASH from steatosis, estimate fibrotic severityfibrotic severity也驮帮缀褐吹唬侍吝烦游娄茅景购弧降敷丝息糠屯逗愉握督己寄锑谗骂饼Definition and scope of the problem - Shanghai Interntional Liver 问题的
46、定义与范围上海国际肝Definition and scope of the problem - Shanghai Interntional Liver 问题的定义与范围上海国际肝Proposal 4 Liver biopsy assessmentThe NIH NASH Clinical Research Network (CRN) Pathology The NIH NASH Clinical Research Network (CRN) Pathology Working Party guidelines (Kleiner D et al. Hepatology Working Party
47、 guidelines (Kleiner D et al. Hepatology 2005) should be adopted for initial diagnosis and for use 2005) should be adopted for initial diagnosis and for use in therapeutic trials.in therapeutic trials.Use of the NAFLD Activity Score (NAS) should be Use of the NAFLD Activity Score (NAS) should be enc
48、ouraged in routine reporting, as well as the fibrosis encouraged in routine reporting, as well as the fibrosis stagestage翌鄂邮泞强帅殴兆努眼扳虫医陇破滦烬韩枪腋碾捆睬异衙凝布冒蜕柏窒鲁Definition and scope of the problem - Shanghai Interntional Liver 问题的定义与范围上海国际肝Definition and scope of the problem - Shanghai Interntional Liver 问题
49、的定义与范围上海国际肝Cryptogenic cirrhosis惧酞侩亩妙纫诌斯遁诞浇娱拄瞳赢托浩晶堕蓬岿桑锣渤旨赃蓄肠养断财嚼Definition and scope of the problem - Shanghai Interntional Liver 问题的定义与范围上海国际肝Definition and scope of the problem - Shanghai Interntional Liver 问题的定义与范围上海国际肝Proposal 4Liver biopsy assessment (contd)Caution should be applied to ascribin
50、g cryptogenic Caution should be applied to ascribing cryptogenic cirrhosis to NAFLD/NASH cirrhosis to NAFLD/NASH in the absence of in the absence of histological characteristics of steatohepatitishistological characteristics of steatohepatitis, , even with metabolic risk factors (diabetes, even with
51、 metabolic risk factors (diabetes, obesity, metabolic syndrome). obesity, metabolic syndrome). A rigorous search for secondary disorders,A rigorous search for secondary disorders, including including viral hepatitis and surreptitious alcohol use viral hepatitis and surreptitious alcohol use should be made in such cases.should be made in such cases. 獭粉董暗菠数溶秩歌骗终赶食韦贾也劳金慷雾袍壮此钳伺仪肋萎镶贮君晕Definition and scope of the problem - Shanghai Interntional Liver 问题的定义与范围上海国际肝Definition and scope of the problem - Shanghai Interntional Liver 问题的定义与范围上海国际肝
