肿瘤合并肝损伤患者血小板减少症管理中国专家共识(2022版)

中国抗癌协会肿瘤支持治疗专业委员会

doi:10.3969/j.issn.1001-5256.2023.06.005

肿瘤合并肝损伤患者血小板减少症管理中国专家共识(2022版)

DOI: 10.3969/j.issn.1001-5256.2023.06.005

中国抗癌协会肿瘤支持治疗专业委员会

利益冲突声明：所有作者声明无利益冲突。

通信作者: 袁响林，yuanxianglin@hust.edu.cn
本文首次发表于[肿瘤防治研究，2023，50(3)：211-223]

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出版历程
- 收稿日期: 2023-04-14
- 录用日期: 2023-05-20
- 出版日期: 2023-06-20

Chinese expert consensus on management of thrombocytopenia in cancer patients with liver injury (2022 edition)

Committee of Neoplastic Supportive-care (CONS), China Anti-Cancer Association

摘要

摘要: 血小板减少症和肝损伤是肿瘤患者常见且严重的临床问题。肿瘤合并肝损伤患者血小板减少症(TCLI)的病因更加复杂，但常见于肝损伤和肿瘤治疗。肿瘤治疗所致血小板减少症的管理已逐渐形成规范，肝损伤相关血小板减少症随着相关药物的获批上市，管理日益明晰。但肿瘤合并肝损伤患者血小板减少症的管理仍是空白，血小板减少症和肝损伤的叠加进一步增加了肿瘤治疗的难度。为此，中国抗癌协会肿瘤支持治疗专业委员会组织专家对文献进行分析和讨论，形成肿瘤合并肝损伤患者血小板减少症管理中国专家共识(2022版)，以指导临床实践。
- 肿瘤 /
- 肝病 /
- 肝损伤 /
- 血小板减少症 /
- 专家共识
Abstract: Thrombocytopenia and liver injury are common and serious clinical problems in cancer patients. The etiology of thrombocytopenia in cancer patients with liver injury (TCLI) is complicated, which is common in liver injury and tumor treatment. The management of cancer therapy-induced thrombocytopenia has gradually become standardized, and the management of liver injury-associated thrombocytopenia is becoming clear with the approval and marketing of relevant drugs. However, the management of TCLI is still blank, and the superposition of thrombocytopenia and liver injury further increases the difficulty of cancer treatment. Therefore, the Committee of Neoplastic Supportive-care, China Anti-Cancer Association organizes experts to analyze and discuss relevant literatures to form a Chinese expert consensus on the management of thrombocytopenia in cancer patients with liver injury (2022 Edition) to guide clinical practice.
- Cancer /
- Liver Disease /
- Liver Injury /
- Thrombocytopenia /
- Expert Consensus

HTML全文

图 1 肿瘤合并原发肝病相关血小板减少症管理流程

Figure 1. Management of thrombocytopenia in cancer patients with primary liver disease

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图 2 MDT执行流程

Figure 2. MDT execution process

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表 1 循证医学证据等级及定义

Table 1. Levels of evidence-based medical proof and definitions

证据等级	定义
Ⅰ级(高质量)	进一步研究几乎不可能改变对临床疗效评估结果的可信度，为高级别证据
Ⅱ级(中等质量)	进一步研究可能改变对疗效评估结果的可信度有重要影响，为中级别证据
Ⅲ级(低质量)	进一步研究很有可能改变对疗效评估结果的可信度有重要影响，且极有可能改变评估结果，为低级别证据
Ⅳ级(极低质量)	任何疗效评估结果都不确定，为极低级别证据

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表 2 推荐级别及定义

Table 2. Recommendation grades and definitions

推荐级别	定义
推荐	基于可获得证据，非常确定获益大于风险和负担，则作出推荐
弱推荐	基于可获得证据，认为获益、风险和负担相当平衡，或获益、风险的程度存在明显不确定性，则作出弱推荐

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表 3 血小板减少症鉴别诊断

Table 3. Differential diagnosis of thrombocytopenia

疾病		检查项目
感染	严重感染	血常规：C反应蛋白；降钙素原
	病毒感染	EB病毒、巨细胞病毒、HIV
血液系统疾病	溶血性贫血；阵发性睡眠血红蛋白尿再生障碍性贫血、肿瘤骨髓转移免疫性血小板减少症	乳酸脱氢酶骨髓涂片、骨髓活检血小板糖蛋白特异性自身抗体
自身免疫性疾病	系统性红斑狼疮、干燥综合征、类风湿关节炎等	抗核抗体、类风湿因子
血栓性疾病	弥漫性血管内凝血	凝血酶原时间、部分活化凝血酶原时间、凝血酶时间、纤维蛋白原、D二聚体、纤维蛋白降解产物
肾功能损伤	肾功能损害相关的血小板减少	肌酐
营养不良	营养不良相关血小板减少	维生素B₁₂、叶酸
抗肿瘤治疗和/或其他药物治疗相关血小板减少症	化疗(如铂类、吉西他滨、卡培他滨、替莫唑胺等)、放疗、免疫检查点抑制剂、靶向治疗(如仑伐替尼、伊马替尼、泽布替尼、尼拉帕利等)、抗体偶联药物(如ADC-恩美曲妥珠单抗等)、抗生素、肝素等	血常规，血小板减少发生前有确切的应用某种引起血小板减少症的药物，且停药后血小板计数恢复正常

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表 4 中国获批上市TPO受体激动剂

Table 4. TPO-RAs approved for marketing in China

项目	罗普司亭	艾曲泊帕	阿伐曲泊帕	海曲泊帕
TPO受体结合形式	胞外	跨膜	跨膜	跨膜
给药途径	皮下注射	口服	口服	口服
饮食影响	无	是	无	是
与阳离子相互作用	无	++	无	++
东亚人群需减少剂量	否	是	否	是
肝功能不全者需减少剂量	否	是	否	是
需增加肝功能检查	否	+	否	?
可否用于肾衰竭	是	可能可以	可能可以	无数据
可否孕期使用	否	否	否	否
国内获批适应证	ITP	ITP	肝病相关血小板减少症	ITP、SAA

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表 5 临床常见引起肝损伤的抗肿瘤药物

Table 5. Common anti-cancer drugs causing liver injury in clinical practice

肿瘤药物分类	典型药物
铂类药物	奥沙利铂、卡铂等
抗代谢药物	甲氨蝶呤、阿糖胞苷、吉西他滨等
烷化剂类药物	环磷酰胺、异环磷酰胺、白消安等
分子靶向类药物	伊马替尼、达沙替尼、拉帕替尼、厄洛替尼、仑伐替尼、索拉非尼、贝伐珠单抗、吉妥珠单抗、曲妥珠单抗等
免疫检查点抑制剂	纳武单抗、帕博利珠单抗、伊匹单抗等
其他	伊立替康、ADCs等

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