Liu Xu-hua, Zheng Su-jun, Zu Ke-jia, Chen Yu, Chen Yi-sen, Wang Tai-ling, Duan Zhong-ping
Beijing Youan Hospital, Capital Medical University, Beijing 100069, China.
Zhonghua Gan Zang Bing Za Zhi. 2010 Oct;18(10):721-5. doi: 10.3760/cma.j.issn.1007-3418.2010.10.001.
In China, liver failure is also termed as severe hepatitis in whom chronic severe hepatitis B (CSHB) is most common. The aim of this study was to assess whether CSHB based on different liver injury extent can meet the international definition of acute-on-chronic liver failure(ACLF)criteria, according by their clinical and pathological feature.
A total of 91 patients with CSHB were involved in the study. The clinical findings, laboratory data and liver pathology features were retrospectively analyzed and grouped by hepatitis virus B carrier state (HBC), chronic hepatitis B (CHB) or liver cirrhosis (LC) before they started liver failure.
74 out of the 91 patients were male and 17 were female, the mean age was 40.6+/-11.2 years. 9.9%, 7.7% and 82.4% of the patients were based on HBC, CHB and LC respectively. The ages of HBC group were youngest. The mean age of HBC group (years) (25.8+/-6.6) was significantly lower than that of CHB group (36.9+/-9.0) and LC group (42.0+/-10.5)with P values of 0.032 and 0.001 respectively. Most cases presented with sub-acute liver failure characterized by high icterus and ascites. Predisposing factors included exertion, superinfection, virus variation, drugs or alcoholic injury. No difference found between PTA (F = 0.906, P = 0.408) and TBil (F = 0.839, P = 0.436) among the above three groups. The Alb and CHE levels in LC group were (30.3+/-5.1) g/L and (2926.8+/-1471.1) U/L respectively, which were lower than both HBC group [Alb (35.6+/-5.1) g/L, CHE (4363.5+/-2063.2) U/L] and CHB group [Alb (37.4+/-5.0) g/L, CHE (5167.1+/-1522.1) U/L] (F = 9.450; F = 9.297; P value less than 0.01).The level of CHO (1.8+/-1.0) mmol/L in LC group was lower than that of HBC group (2.9+/-1.0mmol/L, P = 0.034), while serum HBV DNA level of HBC group [(6.8+/-1.7) log10copies/ml] was higher than that of LC group [(4.2+/-2.6) log10copies/ml]. The liver tissue in HBC and CHB group showed massive or submassive necrosis which distribute evenly in different parts of liver and similarly in slides, most like acute/subacute severe hepatitis. The chronic lesion was easily covered by extensive necrosis in CSHB based on CHB, with portal fibrosis can be seen by masson stain. Characteristic picture of LC group were massive or submassive necrosis with some nodules were intact or only patchy necrosis of the parenchyma, disparity of extent and stage of necrosis existed in slides, which were the major difference in histopathological change in HBC and CHB group.
Most of CSHB cases were based on liver cirrhosis, which match with the international definition of ACLF, while small part of CSHB cases based on HBC and CHB are identical to acute/subacute liver failure.
在中国，肝衰竭也被称为重型肝炎，其中慢性重型乙型肝炎（CSHB）最为常见。本研究旨在根据不同肝损伤程度的CSHB患者的临床和病理特征，评估其是否符合国际上慢加急性肝衰竭（ACLF）的诊断标准。
本研究共纳入91例CSHB患者。回顾性分析其临床症状、实验室检查数据及肝脏病理特征，并根据肝衰竭发生前的乙肝病毒携带状态（HBC）、慢性乙型肝炎（CHB）或肝硬化（LC）进行分组。
91例患者中，男性74例，女性17例，平均年龄为40.6±11.2岁。分别基于HBC、CHB和LC的患者比例为9.9%、7.7%和82.4%。HBC组患者年龄最小。HBC组的平均年龄（岁）（25.8±6.6）显著低于CHB组（36.9±9.0）和LC组（42.0±10.5），P值分别为0.032和0.001。大多数病例表现为以高黄疸和腹水为特征的亚急性肝衰竭。诱发因素包括劳累、重叠感染、病毒变异、药物或酒精损伤。上述三组之间的凝血酶原活动度（PTA）（F = 0.906，P = 0.408）和总胆红素（TBil）（F = 0.839，P = 0.436）无差异。LC组的白蛋白（Alb）和胆碱酯酶（CHE）水平分别为（30.3±5.1）g/L和（2926.8±1471.1）U/L，均低于HBC组[Alb（35.6±5.1）g/L，CHE（4363.5±2063.2）U/L]和CHB组[Alb（37.4±5.0）g/L，CHE（5167.1±1522.1）U/L]（F = 9.450；F = 9.297；P值均小于0.01）。LC组的总胆固醇（CHO）水平（1.8±1.0）mmol/L低于HBC组（2.9±1.0mmol/L，P = 0.034），而HBC组的血清乙肝病毒脱氧核糖核酸（HBV DNA）水平[（6.8±1.7）log10拷贝/ml]高于LC组[（4.2±2.6）log10拷贝/ml]。HBC组和CHB组的肝组织表现为大片或亚大片坏死，均匀分布于肝脏不同部位，切片表现相似，最像急性/亚急性重型肝炎。基于CHB的CSHB中，慢性病变易被广泛坏死掩盖，经Masson染色可见门脉纤维化。LC组的特征性表现为大片或亚大片坏死，部分结节完整或仅实质有片状坏死，切片中坏死程度和阶段存在差异，这是HBC组和CHB组组织病理学变化的主要区别。
大多数CSHB病例基于肝硬化，符合ACLF的国际诊断标准，而少数基于HBC和CHB的CSHB病例与急性/亚急性肝衰竭相同。
