Njei Basile, Do Albert, McCarty Thomas R, Fortune Brett E
*Section of Digestive Diseases ‡Department of Internal Medicine, Yale University School of Medicine †Investigative Medicine Program, Yale Center of Clinical Investigation, New Haven, CT.
J Clin Gastroenterol. 2016 Nov/Dec;50(10):871-881. doi: 10.1097/MCG.0000000000000585.
Despite the significant morbidity and mortality associated with alcoholic hepatitis, a consensus or generally accepted therapeutic strategy has not yet been reached. The purpose of this analysis was to evaluate the effects of corticosteroids and pentoxifylline on short-term mortality, incidence of hepatorenal syndrome, and sepsis in patients with severe alcoholic hepatitis.
We conducted a comprehensive search of the Cochrane library, PUBMED, Scopus, EMBASE, and published proceedings from major hepatology and gastrointestinal meetings from January 1970 to June 2015. All relevant articles irrespective of language, year of publication, type of publication, or publication status were included. Two independent reviewers extracted data and scored publications; a third investigator adjudicated discrepancies. The κ scores were measured to assess the agreement between the 2 initial reviewers. The review and meta-analyses were performed following the recommendations of The Cochrane Collaboration. Conventional meta-analysis and Trial sequential analysis were performed. GRADEpro version 3.6 was used to appraise the quality of epidemiologic evidence.
A total of 14 studies satisfied inclusion criteria comparing corticosteroids, pentoxifylline, or placebo. Compared with placebo, corticosteroids reduced 28-day mortality (RR=0.53; 95% CI, 0.33-0.84; P=0.006). There was no statistically significant difference in short-term mortality between pentoxifylline and placebo (RR=0.74; 95% CI, 0.46-1.18; P=0.21). Neither corticosteroids nor pentoxifylline impacted the incidence of hepatorenal syndrome or sepsis. Trial sequential analysis confirmed the results of our conventional meta-analysis.
Corticosteroids demonstrated a decrease in 28-day mortality in patients with severe alcoholic hepatitis. The evidence from this study is insufficient to support any recommendations regarding the mortality benefit of pentoxifylline in severe alcoholic hepatitis.
尽管酒精性肝炎会导致严重的发病率和死亡率，但尚未达成共识或普遍接受的治疗策略。本分析的目的是评估皮质类固醇和己酮可可碱对重症酒精性肝炎患者短期死亡率、肝肾综合征发病率和败血症的影响。
我们对Cochrane图书馆、PUBMED、Scopus、EMBASE以及1970年1月至2015年6月期间主要肝病学和胃肠病学会议上发表的会议记录进行了全面检索。纳入所有相关文章，无论其语言、发表年份、出版物类型或发表状态如何。两名独立的审阅者提取数据并对出版物进行评分；第三名研究者对差异进行裁决。测量κ评分以评估两名初始审阅者之间的一致性。按照Cochrane协作网的建议进行综述和荟萃分析。进行了传统的荟萃分析和试验序贯分析。使用GRADEpro 3.6版评估流行病学证据的质量。
共有14项研究符合纳入标准，比较了皮质类固醇、己酮可可碱或安慰剂。与安慰剂相比，皮质类固醇降低了28天死亡率（RR=0.53；95%CI，0.33-0.84；P=0.006）。己酮可可碱和安慰剂之间的短期死亡率无统计学显著差异（RR=0.74；95%CI，0.46-1.18；P=0.21）。皮质类固醇和己酮可可碱均未影响肝肾综合征或败血症的发病率。试验序贯分析证实了我们传统荟萃分析的结果。
皮质类固醇可降低重症酒精性肝炎患者的28天死亡率。本研究的证据不足以支持关于己酮可可碱对重症酒精性肝炎死亡率有益的任何建议。
