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2012美国非酒精性脂肪肝(NAFLD)临床实践指南

2012-06-26 MedSci MedSci原创

 近日,美国胃肠病协会、美国肝病研究学会、美国胃肠病学会共同发表《非酒精性脂肪肝临床实践指南》,该指南已经联合发表在2012年6月的美国《胃肠病》、《肝病》和《美国胃肠病学杂志》上。指南共涉及45条推荐意见,“1或2”为推荐强度,“A、B、C”为证据的等级。   [1]临床疑诊非酒精性脂肪性肝病(nonalcoholic fatty liver disease,&n

 近日,美国胃肠病协会、美国肝病研究学会、美国胃肠病学会共同发表《非酒精性脂肪肝临床实践指南》,该指南已经联合发表在2012年6月的美国《胃肠病》、《肝病》和《美国胃肠病学杂志》上。指南共涉及45条推荐意见,“1或2”为推荐强度,“A、B、C”为证据的等级。

  [1]临床疑诊非酒精性脂肪性肝病(nonalcoholic fatty liver disease, NAFLD)时,需评估其近期饮酒情况。规定男性每周平均饮酒量超过21个单位(210g 乙醇,女性为14个单位)为过量饮酒。(2, C)

  [2]对于影像学检测明确有肝脂肪变并且存在肝病症状、体征或肝脏生化指标异常的患者,在考虑NAFLD之前须做进一步评估以完善诊断。(1, A)

  [3]对于影像学检测明确有肝脂肪变,但不存在任何肝病相关症状、体征,并且肝脏生化指标正常的患者,应该评估代谢性危险因素(如肥胖、糖耐量异常、血脂异常)以及其它可能导致肝脂肪变的病因(如大量饮酒或药物)。(1, A)

  [4]对于影像学检测明确有肝脂肪变,但不存在任何肝病相关症状且肝脏生化指标正常的患者,不推荐肝活检组织学检查。(1, B)

  [5]鉴于NAFLD的诊断与治疗方案尚不明确,至今对其长远利益和成本-效益评估尚不完善,因此不建议在初级卫生服务诊所、糖尿病或肥胖症成人专科诊所筛查NAFLD。(1, B)

  [6]目前不建议对NAFLD进行家庭成员的系统筛查。(1, B)

  [7]当疑诊NAFLD时,排除导致肝细胞脂肪变的其它病因和现有常见的慢性肝病至关重要。

  [8]推荐给血清铁和转铁饱和度持续升高尤其是原发性血色病基因(HFE)有C282Y突变的纯合子或杂合子患者作肝活检。(1, A)

  [9]对于高滴度自身抗体阳性且存在转氨酶和球蛋白显著升高等患者,需进一步检查排除自身免疫性肝病。(1, B)

  [10]代谢综合征可预测NAFLD患者存在脂肪性肝炎(nonalcoholic steatohepatitis, NASH),此类病例需作肝活检明确诊断。(1, B)

  [11] NAFLD纤维化评分对于鉴别患者是否存在桥接纤维化和/或肝硬化是一个十分有效的临床工具。(1, B)

  [12]尽管血清或血浆细胞角蛋白(CK)-18是一个鉴别NASH的有效生物标记物,但临床常规检测尚不成熟。(1, B)

  [13]对于存在脂肪性肝炎和进展期肝纤维化风险的NAFLD患者须进行肝活检。(1, B)

  [14]代谢综合征和NAFLD纤维化评分可以用来评估患者是否存在脂肪性肝炎和进展期纤维化。(1, B)

  [15]对于疑诊为NAFLD,但可能有导致肝脂肪变的其它病因或者并存其他慢性肝病时,推荐进行肝活检。(1, B)

  [16]通过低热量饮食伴或不伴体育锻炼来减轻体重,通常都可以减少肝脏脂肪沉积。 (1, A)

  [17]体重至少下降3-5%才能改善肝脂肪变,但是只有高达10%的体重下降才能改善肝脏的炎症坏死程度。 (1, B)

  [18] NAFLD成人单纯通过锻炼可能只减轻肝脂肪变,锻炼对其他肝组织学指标的改善作用仍待明确。 (1, B)

  [19]二甲双胍并不能改善成人NAFLD患者的肝组织学损害,故不推荐用于非酒精性脂肪性肝炎(NASH)成人肝病的治疗。(1, A)

  [20]皮格列酮可用于肝活检证实的NASH患者。然而现有随机对照试验(RCT)主要将其用于无糖尿病的NASH患者,该药长期应用的效果和安全性尚待明确。 (1, B)

  [21]维生素E (α-生育酚,800 IU/d) 可改善无糖尿病的NASH成人的肝组织学损伤,故可作为无糖尿病的NASH成人的一线治疗药物。 (1B)

  [22]目前还不能推荐维生素E用于治疗合并糖尿病的NASH、没有肝活检的资料的NAFLD、NASH相关肝硬化或隐源性肝硬化。(1C)

  [23]不推荐应用熊去氧胆酸治疗NAFLD或NASH。(1, B)

  [24]目前尚无足够依据推荐omega-3脂肪酸治疗NAFLD或NASH,但其可作为NAFLD患者高甘油三酯血症治疗的一线治疗药物。(1, B)

  [25]NAFLD或NASH不是肥胖症患者前肠减肥手术的禁忌证,除非有明确的肝硬化. (1, A)

  [26]对于NAFLD导致的肝硬化且各方面符合减肥手术的患者而言,减肥手术的类型、安全性和有效性尚缺乏支持性依据。(I,B)

  [27]将减肥手术作为NASH患者的一项成熟性治疗手段推荐为时尚早。(I,B)

  [28]NAFLD患者不能过量饮酒。(I,B)

  [29]对于不饮酒或仅少量饮酒的NAFLD患者对于饮酒问题暂无任何推荐意见。(I,B)

  [30]鉴于没有证据显示NAFLD和NASH患者使用他汀易发生严重的药物性肝损伤,为此他汀类药物可以用于NAFLD和NASH患者血脂紊乱的治疗。(I,B)

  [31]除非通过肝组织学终点的RCTs证实他汀类药物的有效性,否则其不应作为NASH的特异性治疗措施。(I,B)

  [32]当其他类型的慢性肝病发现明显的脂肪变性和脂肪性肝炎时,必须评价代谢性危险因素和其他可能的病因在肝脂肪变中的作用。(1, B)

  [33]在其他类型的慢性肝病并存NAFLD和NASH时,没有任何数据支持维生素E可以改善肝病。(I,B)

  [34]NASH肝硬化患者应该根据AASLD/AGA实践指南进行胃食管静脉曲张的筛查。(I,B)

  [35]NASH肝硬化患者应该考虑根据AASLD/AGA实践指南进行肝细胞性肝癌的筛查。(IB)

  [36]现有证据并不支持常规对非酒精性单纯性脂肪肝(NAFL)或NASH患者动态肝活检。(I,C)

  [37]儿童脂肪肝患者如果年龄非常小且没有超重应考虑单因素所致慢性肝病,如脂肪酸氧化缺陷、溶酶体贮积病和过氧化物酶体疾病,同理对于类似的成人亦应考虑到这些疾病的可能。(2,C)

  [38]NAFLD患儿血清常出现低滴度的自身抗体,但是如果自身抗体的滴度较高且伴血清转氨酶明显异常和高丙种球蛋白血症,则应进行肝活检以评价自身免疫性肝炎的可能。(2,B)

  [39]尽管近来有一个专家委员会推荐超重和肥胖儿童每两年检测一次肝功能,但由于缺乏足够证据现尚不推荐在超重和肥胖儿童中筛查NAFLD。(I,B)

  [40]疑有NAFLD的儿童,如果其NAFLD的诊断不明确,或者存在多种疾病可能,或者需要应用有潜在肝毒性的药物,由需进行肝活检组织学检查。 (1, B)

  [41]在对儿童进行针对NASH的药物治疗之前必须通过肝活检明确NASH的诊断。 (2, C)

  [42]肝脏病理专家在阅读儿童肝活检标本时,应认识至儿童NAFLD常有其有特殊的类型,勿因成人肝脏病理经验而误判。 (1, B)

  [43]强化改变生活方式可降低NAFLD儿童的血清转氨酶水平并对肝组织学有改善作用,为此应作为NAFLD儿童的一线治疗措施。2, B)

  [44]二甲双胍(500 mg,tid)对NAFLD儿童肝脏损害并无治疗作用,为此不推荐应用该药。目前尚不知道加大剂量是否会有效。(1, B)

  [45]维生素E(α-生育酚)每天800 IU对肝活检证实的NASH以及可疑NASH儿童的肝组织学损害有改善作用,但仍需进一步研究证实,暂不推荐将其用于常规治疗。(1,B)

  相关链接:Societies Develop New NAFLD Clinical Practice Guideline

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    2013-04-28 lvygwyt2781
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