Diagnosis and Treatment of Alcohol-Associated Liver Diseases: 2019 Practice Guidance From the American Association for the Study of Liver Diseases
Diagnosis and Treatment of Alcohol-Associated Liver Diseases: 2019 Practice Guidance From the American Association for the Study of Liver Diseases
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DOI：
10.1002/hep.30866
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发表时间：
2020-01-01
期刊：
影响因子：
13.5
通讯作者：
Lucey, Michael R.
中科院分区：
文献类型：
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作者：
Crabb, David W.;Im, Gene Y.;Lucey, Michael R.
酒精相关性肝病(ALD)是由酒精引起的一系列肝脏损伤，从肝脏脂肪变性到更高级的形式，包括酒精性肝炎(AH)、酒精性肝硬变(AC)和急性酒精性肝炎(AH)，表现为急性-慢性肝衰竭。ALD是世界范围内肝脏疾病的主要原因，它本身以及作为慢性病毒性肝炎、非酒精性脂肪性肝病(NAFLD)、铁超载和其他肝病进展的辅助因素。ALD的发展经历了几个阶段，从肝脏脂肪变性开始，在某些人中，逐渐发展到AH(其组织学上的相关性是酒精性脂肪性肝炎)，最终发展到肝硬变(图1)。(1，2)这些不同阶段的进展取决于持续大量饮酒和其他危险因素，包括女性、遗传易感性、饮食和合并肝病。ALD在社会上是一种严重的耻辱。越来越多的提供者认识到，患者及其家人试图减少ALD的耻辱，将“酒精”一词改为“酒精相关”将有所帮助；因此，建议使用酒精相关性肝病、酒精相关性脂肪性肝炎和酒精相关性肝硬变，保留熟悉的缩写(分别为ALD、ASH和AC)。由于长期使用，“酒精性肝炎”这一术语很可能会继续存在。这份2019年ALD指南为ALD和酒精使用障碍(AUD)的患病率、临床频谱、诊断和临床管理提供了一种数据支持的方法。该指南是根据一个专家小组的协商一致意见编写的，并在正式审查和分析已发表的有关专题的文献的基础上提供了指导声明。证据的质量(水平)和每个指导性声明的力度都不是正式评级。2010年指南的更新包括强调AUD的定义、筛查和治疗；新的酒精生物标志物；额外的遗传和环境易感因素；共识缩写：ABIC，年龄，血清胆红素，国际标准化比率，和血清肌酐；AC，酒精性肝硬变；AH，酒精性肝炎；AKI，急性肾损伤；ALD，酒精性肝病；AUD，酒精使用障碍；AUOC，受试者操作特征曲线下的面积；BMI，体重指数；CDT，碳水化合物缺乏转铁蛋白；CI，可信区间；CPT，Child-Pugh-Turcotte；EtG，乙基葡萄糖苷；ETS，乙硫酸乙酯；AUROC，接受者操作特征曲线下的面积；BMI，体重指数；CDT，碳水化合物缺乏转铁蛋白；CI，可信区间；CPT，Child-Pugh-Turcotte；EtG，乙基葡萄糖苷；ETS，乙硫酸乙酯；FDA，食品和药物管理局；GAHS，格拉斯哥酒精性肝炎评分；G-CSF，粒细胞集落刺激因子；GGT，谷氨酰转移酶；GIB，胃肠道出血；肝癌，肝细胞癌；丙型肝炎病毒；LT，肝移植；MDF，Maddrey判别函数；MELD，终末期肝病模型；MRI，磁共振成像；NAC，N-乙酰半胱氨酸；NAFLD，非酒精性脂肪性肝病；NASH，非酒精性脂肪性肝炎；NIAAA，国家酒精滥用和酒精中毒研究所；Peth，磷脂醇；RCT，随机对照试验；SIRS，全身炎症反应；STOPAH，类固醇或己酮可可碱，用于酒精性肝炎；器官共享联合网络。
Alcohol-associated liver disease (ALD) represents a spectrum of liver injury resulting from alcohol use, ranging from hepatic steatosis to more advanced forms including alcoholic hepatitis (AH), alcohol-associated cirrhosis (AC), and acute AH presenting as acute-onchronic liver failure. ALD is a major cause of liver disease worldwide, both on its own and as a co-factor in the progression of chronic viral hepatitis, nonalcoholic fatty liver disease (NAFLD), iron overload, and other liver diseases. ALD develops through several stages, beginning with hepatic steatosis, and, in some individuals, gradually progressing through AH (the histological correlate of which is alcoholic steatohepatitis), culminating in cirrhosis (Fig. 1).(1, 2) Progression through these various stages is dependent on continued heavy alcohol use and other risk factors, including female sex, genetic susceptibility, diet, and comorbid liver disease. ALD carries a significant stigma in society. It is increasingly recognized by providers that patients and their families seek to reduce the stigma of ALD, and a change from the term “alcoholic” to “alcohol-associated” will help; thus, alcohol-associated liver disease, alcohol-associated steatohepatitis, and alcohol-associated cirrhosis are suggested, retaining the familiar abbreviations (ALD, ASH, and AC, respectively). Due to longstanding usage, the term “alcoholic hepatitis” will likely persist. This 2019 ALD Guidance provides a data-supported approach to the prevalence, clinical spectrum, diagnosis, and clinical management of ALD and alcohol use disorders (AUDs). The Guidance was developed by consensus of an expert panel and provides guidance statements based on formal review and analysis of published literature on the topics. The quality (level) of the evidence and the strength of each guidance statement are not formally rated. Updates to the 2010 Guideline include an emphasis on AUD definition, screening, and treatment; new alcohol biomarkers; additional genetic and environmental susceptibility factors; a consensusAbbreviations: ABIC, age, serum bilirubin, international normalized ratio, and serum creatinine; AC, alcoholic cirrhosis; AH, alcoholic hepatitis; AKI, acute kidney injury; ALD, alcoholic liver disease; AUD, alcohol use disorder; AUDIT, Alcohol Use Disorders Inventory Test; AUROC, area under the receiver operating characteristics curve; BMI, body mass index; CDT, carbohydrate-deficient transferrin; CI, confidence interval; CPT, Child-Pugh-Turcotte; EtG, ethyl glucuronide; EtS, ethyl sulfate; FDA, Food and Drug Administration; GAHS, Glasgow Alcoholic Hepatitis Score; G-CSF, granulocyte-colony stimulating factor; GGT, gamma-glutamyl transferase; GIB, gastrointestinal bleeding; HCC, hepatocellular carcinoma; HCV, hepatitis C virus; LT, liver transplantation; MDF, Maddrey discriminant function; MELD, Model for End-Stage Liver Disease; MRI, magnetic resonance imaging; NAC, N-acetylcysteine; NAFLD, nonalcoholic fatty liver disease; NASH, nonalcoholic steatohepatitis; NIAAA, National Institute on Alcohol Abuse and Alcoholism; PEth, phosphatidylethanol; RCT, randomized controlled trial; SIRS, systemic inflammatory response syndrome; STOPAH, Steroids or Pentoxifylline for Alcoholic Hepatitis; UNOS, United Network for Organ Sharing.