中文English
ISSN 1001-5256 (Print)
ISSN 2097-3497 (Online)
CN 22-1108/R

留言板

尊敬的读者、作者、审稿人, 关于本刊的投稿、审稿、编辑和出版的任何问题, 您可以本页添加留言。我们将尽快给您答复。谢谢您的支持!

姓名
邮箱
手机号码
标题
留言内容
验证码

慢加急性肝衰竭合并感染的诊治

陆霭琪 杨可立 关玉娟

引用本文:
Citation:

慢加急性肝衰竭合并感染的诊治

DOI: 10.3969/j.issn.1001-5256.2019.11.046
基金项目: 

广东省医学科学技术研究基金项目(A2019296); 

详细信息
  • 中图分类号: R575.3

Research advances in the diagnosis and treatment of acute-on-chronic liver failure with infection

Research funding: 

 

  • 摘要: 慢加急性肝衰竭(ACLF)是临床常见的严重肝病症候群,可以导致肝脏合成、代谢、解毒和生物转化等功能的严重障碍和失代偿,并导致多器官功能衰竭和短期内极高的病死率。感染可以诱发或者加重ACLF病情,是患者预后的独立影响因素。简述了ACLF合并感染的机制与特征,归纳了常见的感染类型及临床特征,总结了目前推荐的抗感染方案,提出早期预防性治疗的重要性。ACLF患者合并感染的病情危重,早期诊断和经验性的抗感染治疗是关键。

     

  • [1] SARIN SK,KEDARISETTY CK,ABBAS Z,et al. Acute-onchronic liver failure:Consensus recommendations of the Asian Pacific Association for the Study of the Liver(APASL)2014[J]. Hepatol Int,2014,8(4):453-471.
    [2] SARIN SK,CHOUDHURY A,SHARMA MK,et al. Acute-on-chronic liver failure:consensus recommendations of the Asian Pacific association for the study of the liver(APASL):An update[J]. Hepatol Int,2019,13(4):353-390.
    [3] MOREAU R,JALAN R,GINES P,et al. Acute-on-chronic liver failure is a distinct syndrome that develops in patients with acute decompensation of cirrhosis[J]. Gastroenterology,2013,144(7):1426-1437.
    [4] ARROYO V,MOREAU R,KAMATH PS,et al. Acute-onchronic liver failure in cirrhosis[J]. Nat Rev Dis Primers,2016,2:16041.
    [5] MOREAU R. The pathogenesis of ACLF:The inflammatory response and immune function[J]. Semin Liver Dis,2016,36(2):133-140.
    [6] GUSTOT T,DURAND F,LEBREC D,et al. Severe sepsis in cirrhosis[J]. Hepatology,2009,50(6):2022-2033.
    [7] TAKEUCHI O,AKIRA S. Pattern recognition receptors and inflammation[J]. Cell,2010,140(6):805-820.
    [8] MEDZHITOV R. Origin and physiological roles of inflammation[J]. Nature,2008,454(7203):428-435.
    [9] IWASAKI A,MEDZHITOV R. Control of adaptive immunity by the innate immune system[J]. Nat Immunol,2015,16(4):343-353.
    [10] KONO H,ROCK KL. How dying cells alert the immune system to danger[J]. Nat Rev Immunol,2008,8(4):279-289.
    [11] HERNAEZ R,SOLA E,MOREAU R,et al. Acute-on-chronic liver failure:An update[J]. Gut,2017,66(3):541-553.
    [12] FERNANDEZ J,ACEVEDO J,WIEST R,et al. Bacterial and fungal infections in acute-on-chronic liver failure:Prevalence,characteristics and impact on prognosis[J]. Gut,2018,67(10):1870-1880.
    [13] BAJAJ JS,O'LEARY JG,REDDY KR,et al. Second infections independently increase mortality in hospitalized patients with cirrhosis:The North American consortium for the study of end-stage liver disease(NACSELD)experience[J]. Hepatology,2012,56(6):2328-2335.
    [14] SHI Y,YANG Y,HU Y,et al. Acute-on-chronic liver failure precipitated by hepatic injury is distinct from that precipitated by extrahepatic insults[J]. Hepatology,2015,62(1):232-242.
    [15] BELLOT P,FRANCES R,SUCH J. Pathological bacterial translocation in cirrhosis:Pathophysiology,diagnosis and clinical implications[J]. Liver Int,2013,33(1):31-39.
    [16] WASMUTH HE,KUNZ D,YAGMUR E,et al. Patients with acute on chronic liver failure display"sepsis-like"immune paralysis[J]. J Hepatol,2005,42(2):195-201.
    [17] BERNSMEIER C,TRIANTAFYLLOU E,BRENIG R,et al. CD14(+)CD15(-)HLA-DR(-)myeloid-derived suppressor cells impair antimicrobial responses in patients with acute-onchronic liver failure[J]. Gut,2018,67(6):1155-1167.
    [18] APPENRODT B,GRUNHAGE F,GENTEMANN MG,et al. Nucleotide-binding oligomerization domain containing 2(NOD2)variants are genetic risk factors for death and spontaneous bacterial peritonitis in liver cirrhosis[J]. Hepatology,2010,51(4):1327-1333.
    [19] SENKERIKOVA R,de MARE-BREDEMEIJER E,FRANKOVA S,et al. Genetic variation in TNFA predicts protection from severe bacterial infections in patients with end-stage liver disease awaiting liver transplantation[J]. J Hepatol,2014,60(4):773-781.
    [20] NISCHALKE HD,BERGER C,ALDENHOFF K,et al. Toll-like receptor(TLR)2 promoter and intron 2 polymorphisms are associated with increased risk for spontaneous bacterial peritonitis in liver cirrhosis[J]. J Hepatol,2011,55(5):1010-1016.
    [21] HASSAN EA,ABD EL-REHIM AS,HASSANY SM,et al. Fungal infection in patients with end-stage liver disease:Low frequency or low index of suspicion[J]. Int J Infect Dis,2014,23:69-74.
    [22] European Association for the Study of the Liver. EASL clinical practice guidelines on the management of ascites,spontaneous bacterial peritonitis,and hepatorenal syndrome in cirrhosis[J]. J Hepatol,2010,53(3):397-417.
    [23] NAHON P,LESCAT M,LAYESE R,et al. Bacterial infection in compensated viral cirrhosis impairs 5-year survival(ANRS CO12Cir Vir prospective cohort)[J]. Gut,2015,66(2):330-341.
    [24] BAJAJ JS,O'LEARY JG,RAJENDER KR,et al. Survival in infection-related acute-on-chronic liver failure is defined by extrahepatic organ failures[J]. Hepatology,2014,60(1):250-256.
    [25] MANDELL LA,WUNDERINK RG,WATERER GW. Community-acquired pneumonia[J]. N Engl J Med,2015,373(3):292-294
    [26] FERNANDEZ J,ACEVEDO J,WIEST R,et al. Bacterial and fungal infections in acute-on-chronic liver failure:prevalence,characteristics and impact on prognosis[J]. Gut,2018,67(10):1870-1880.
    [27] BAJAJ JS,O'LEARY JG,WONG F,et al. Bacterial infections in end-stage liver disease:Current challenges and future directions[J]. Gut,2012,61(8):1219-1225.
    [28] VERMA N,SINGH S,TANEJA S,et al. Invasive fungal infections amongst patients with acute-on-chronic liver failure at high risk for fungal infections[J]. Liver Int,2019,39(3):503-513.
    [29] Society of Infectious Diseases,Chinese Medical Association.Expert consensus on diagnosis and treatment of end-stage liver disease complicated infection[J]. J Clin Hepatol,2018,34(9):1862-1872.(in Chinese)中华医学会感染病学分会.终末期肝病合并感染诊治专家共识[J].临床肝胆病杂志,2018,34(9):1862-1872.
    [30] STRNAD P,TACKE F,KOCH A,et al. Liver-guardian,modifier and target of sepsis[J]. Nat Rev Gastroenterol Hepatol,2017,14(1):55-66.
    [31] WIEST R,ALBILLOS A,TRAUNER M,et al. Targeting the gutliver axis in liver disease[J]. J Hepatol,2017,67(5):1084-1103.
    [32] VICTOR DW 3rd,QUIGLEY EM. Microbial therapy in liver disease:Probiotics probe the microbiome-gut-liver-brain axis[J]. Gastroenterology,2014,147(6):1216-1218.
    [33] MERLI M,LUCIDI C,di GREGORIO V,et al. The chronic use of beta-blockers and proton pump inhibitors may affect the rate of bacterial infections in cirrhosis[J]. Liver Int,2015,35(2):362-369.
    [34] UBEDA M,LARIO M,MUNOZ L,et al. Obeticholic acid reduces bacterial translocation and inhibits intestinal inflammation in cirrhotic rats[J]. J Hepatol,2016,64(5):1049-1057.
    [35] MOOKERJEE RP,PAVESI M,THOMSEN KL,et al. Treatment with non-selective beta blockers is associated with reduced severity of systemic inflammation and improved survival of patients with acute-on-chronic liver failure[J]. J Hepatol,2016,64(3):574-582.
    [36] MADSEN B S,HAVELUND T,KRAG A. Targeting the gut-liver axis in cirrhosis:Antibiotics and non-selective betablockers[J]. Adv Ther,2013,30(7):659-670.
    [37] de FRANCHIS R. Expanding consensus in portal hypertension:Report of the Baveno VI Consensus Workshop:Stratifying risk and individualizing care for portal hypertension[J]. J Hepatol,2015,63(3):743-752.
    [38] HORVATH A,LEBER B,SCHMERBOECK B,et al. Randomised clinical trial:The effects of a multispecies probiotic vs.placebo on innate immune function,bacterial translocation and gut permeability in patients with cirrhosis[J]. Aliment Pharmacol Ther,2016,44(9):926-935.
    [39] GARCIA-MARTINEZ R,CARACENI P,BERNARDI M,et al.Albumin:Pathophysiologic basis of its role in the treatment of cirrhosis and its complications[J]. Hepatology,2013,58(5):1836-1846.
    [40] GUSTOT T. Beneficial role of G-CSF in acute-on-chronic liver failure:Effects on liver regeneration,inflammation/immunoparalysis or both?[J]. Liver Int,2014,34(4):484-486.
    [41] KHANAM A,TREHANPATI N,GARG V,et al. Altered frequencies of dendritic cells and IFN-gamma-secreting T cells with granulocyte colony-stimulating factor(G-CSF)therapy in acute-on-chronic liver failure[J]. Liver Int,2014,34(4):505-513.
    [42] KEDARISETTY CK,ANAND L,BHARDWAJ A,et al. Combination of granulocyte colony-stimulating factor and erythropoietin improves outcomes of patients with decompensated cirrhosis[J].Gastroenterology,2015,148(7):1362-1370. e7.
    [43] ROBERTO C,ENRICO G. Historical review of thymosinα1 in infectious diseases[J]. Expert Opin Biol Ther,2015,15(Suppl 1):s117-s127.
    [44] ANTY R,TONOHOUAN M,FERRARI-PANAIA P,et al. Low levels of 25-hydroxy vitamin D are independently associated with the risk of bacterial infection in cirrhotic patients[J]. Clin Transl Gastroenterol,2014,5:e56.
    [45] European Association for the Study of the Liver. EASL clinical practice guidelines on the management of ascites,spontaneous bacterial peritonitis,and hepatorenal syndrome in cirrhosis[J]. J Hepatol,2010,53(3):397-417.
    [46] FERNANDEZ J,BERT F,NICOLAS-CHANOINE MH. The challenges of multi-drug-resistance in hepatology[J]. J Hepatol,2016,65(5):1043-1054.
    [47] PIANO S,FASOLATO S,SALINAS F,et al. The empirical antibiotic treatment of nosocomial spontaneous bacterial peritonitis:Results of a randomized,controlled clinical trial[J]. Hepatology,2016,63(4):1299-1309.
    [48] MERLI M,LUCIDI C,di GREGORIO V,et al. An empirical broad spectrum antibiotic therapy in health-care-associated infections improves survival in patients with cirrhosis:A randomized trial[J]. Hepatology,2016,63(5):1632-1639.
  • 加载中
计量
  • 文章访问数:  1098
  • HTML全文浏览量:  24
  • PDF下载量:  296
  • 被引次数: 0
出版历程
  • 收稿日期:  2019-06-17
  • 出版日期:  2019-11-20
  • 分享
  • 用微信扫码二维码

    分享至好友和朋友圈

目录

    /

    返回文章
    返回