484! "# Chin J Gastroenterol Hepatol,Jun 2010,Vol 19,No 6 0 NAFL '! P! X,0 I? 3 \! N b VW [1,2,9,13,14] # \ X -,NAFLD N [ #2? ALT γ <(GGT)

Transcript

1 56789:8Q (2010? ) Z[\ RS!;TU;VW;XM[ Y ]; Guidelines for management of nonalcoholic fatty liver disease:an updated and revised edition The Chinese National Work shop on Fatty Liver and Alcoholic Liver Disease for the Chinese Liver Disease Association. Key words Fatty liver;diagnosis / therapy;guidebooks [Pub lication type];metabolic syndrome Z[ \ R S \! (NAFLD)] \ ^ _ ` a b c (insulin resistance,ir) Q \!, _ Z [ \! (ALD), N Z, Z [\ \ R S! (nonalcoholic simple fatty liver, NAFL) Z[ \ R S \! (NASH)! P! [1,2] NAFLD ] 21 U S \, ] \! [3] \ NAFLD T U V W,! RS! KLMN:,O K G G P K Q ,E mail:fanjiangao@ gmail. com Z[\! a, K TW O [4 9],, 2006 Z[\RS\!TWXM [10] 3 5 [11], YK A, 1 1 ]^ E _`a M Ⅰ Ⅱ 1 Ⅱ 2 Ⅱ 3,2 Ⅲ, XM ] NAFLD TU NAFLD TU VW!",#] \$%,&#'! V W a \() N, * +, -a W./,0 U1 N() O, 2, TW3 4 5' NAFLD 6 7 8, X M 9 : Q 6 ; #U 1 b NAFLD ] 3 X! < = > \! >?,@K A NAFLD B 20% ~ 33%, NASH! P 10% ~ 20% 2% ~ 3% [1,2,12] CDE N NAFL B 60% ~ 90% NASH 20% ~ 25%! P 2% ~ 8%,2 R E N NAFLD B 28% ~ 55% 27% ~ 92% [1,2,12,13] C D E U, NAFLD F7 8GHI5PXJK, O DL X W A NAFLD B 15% MN [3] NAFLD O? b : R S PQ R S 3 T,IR (CD U RVW Z[ 2 ) [3,12,13] XY! (HCV) _! R S, ]U RS! _CDE B 78 F [3,12,14] Z [H \<]W $ % T U C D E,) ^ X (body mass index,bmi) ( )_` > NAFLD N \W 9 # Q [3,12,13] ) ^ _ ` a _ NAFLD X a,_ ` b BMI % c R S! [3,12,13]? 3 HCV N! (HBV) N!RS _ IR VWa ;NAFLD ] HBV DNA I \ HBV N < >? [3,4,16] 2 c A NAFLD N! 6 8! '! S (! S ) NAFL 6, 10 ~ 20! PX BI(0 6% ~ 3%), NASH N 10 ~ 15 K! P X B 15% ~ 25% [1,2] 5 > 50 CD( ]K \CD) U 2 ALT AST _ ALT b > 1 ( F Q X$] NASH 6\! P O?b [1,2,9,17] NAFLD FD,NASH NAFL X! P 3 [1,2] _ \! Z[\! b,nash N! P 6,! P! K > X ' A [1,2,13,17] ' IR ),NAFL ]X NASH! P ;RS!! ^ / \,NAFL M! ' Q X X \! [13,16], \! N,

2 484! "# Chin J Gastroenterol Hepatol,Jun 2010,Vol 19,No 6 0 NAFL '! P! X,0 I? 3 \! N b VW [1,2,9,13,14] # \ X -,NAFLD N [ #2? ALT γ <(GGT) N]c,? \ R P \ Y! P [1,2,9] NAFL NU? B 0# I' NASH, N! B A a [1,2,9] NAFLD( NAFL)_?,NAFLD ' b BMI R)CD _ ` K \ C D c O? b [3,13,18,19] Z])^ > NAFLD N, 6 ~ 15 2 XB9 [2,3,9,13,18,19] 3 QR ]^ 1 QR/0 1. TU:2 NAFLD TU; 3 [3 5,9,10] :(1) Z Z (' 140 g / 2( \ < 70 g / 2);(2) \! \! U! \ \! ' R S! ;(3)! S RS\! TU$% '! T U,NAFLD M :(1)! - \ R S! T U $ %G?' [4] ; ( )(2)a N-#2? ALT AST GGT O [4,5,9] C ( ) IR,=>< RS! >N' 2 NAFLD TU [4,5,9] 2. TU:NAFLD! 3 \ \! RS, # a! ( K \ E 2 P [4,5,9,20] _ A#,!" NASH # Y ( E P)K > ( K $ [21] NAFLD TU W%&' =H G NASH M XM,> NAFLD SR (NAFLD activity score,nas)! P [4,20] NAS (0 ~ 8 ):(1)! RS :0 (< 5%);1 (5% ~ 33%);2 (34% ~ 66%);3 (> 66%) (2)( K E(20 F ):0 ( );1 (< 2 );2 (2 ~ 4 );3 (> 4 ) (3)! :0, ;1,Q ;2, NAS & T U D (,NAS < 3 ' ) NASH,NAS > 4 'TU NASH,*'+N N NASH ' [20] # a( K E P! R S > 33% N NAFL,R S #, D N-! RS [10]! P (0 ~ 4):0: P;1a:! 3. 2 P;1b:! 3 2 P; 1c:-a/ 2` P;2: 3 2 P 0 / 2` P;3:01 P;4: ' T! P, NASH 0! P RS\! P / \! P(?!RS E! P 6.) #.Q: ars\! /\! P?' NAFLD, 2a '! P? [4,20] 3. TU: (3 3 4& N \ R S! [4] :(1)! \ ( 2 E! ),8 6 ' 9 ;(2)! K Y : # ;(3)! 786; CT TU I,! / CT b(' 1 0,! / CT b (' 1 0 ' 0 7 N., 0 7 ' 0 5 N, 0 5 N RS! [10] 4. TU: T U 2005 <=$%, 5 3 N T U [4,22] :(1)C D E:_` > 90 cm(>\),> 80 cm( \), ( )BMI > 25 kg / m 2 (2)?@*A(TG) : TG 1 7 mmol / L, BT U TG E (3) R C DE (high density lipoprotein cholesterol,hdl C) I:HDL C < 1 03 mmol / L(>\),< 1 29 mmol / L( \) (4) U :R U 130 / 85 mm Hg(1 mm Hg = kpa) BTU U (5) 4 (fasting plasma glucose,fpg) :FPG 5 6 mmol / L BTU 2 ]^ 2 /0 1. : RS! ' NAFLD,; Z[\!(ALD) \! \!! \ ' RS!!; ( 4 F G H I J K L M^ b ) U E\ J NE O β RC E \ _ IR (R^ \ Mauriac ) ' RS! P [4 10,16] 2. : < ( )GGT ' NAFLD,; \! ALD \!! \ α 1 `C < E!;! \ D:, Q K3 Q '! < R

3 N [4 10] 3. ' Z \ HBV? 3 HCV N,0 \ R S! K > ' NAFLD S [14 16] ' < = > HB sag \ N,T HBV DNA I ' 10 4 U V / ml G O?b, <=> a' ]5 NAFLD [4,15,16] 4. 2 *'Q (>\ < 140 g / 2, \ < 70 g / 2) (>\ > 280 g / 2, \ > 140 g / 2) N, < => RS!?K>,W X N; Z[?b 0 ' [4,16], ' 0Y! -E ( )Z[ N,; \! _ RS\! ALD _ NAFLD 0 ' [16] ]^ 3 1. ' O?b(K \CD 2 RVW U, )^ a ) N, ; & ' 9 Z a, [>! \O4&56 [4 10,13,23,24] 2. ' E \!! < = > ( ) \RS! N, [ \ ] 0\,2 a!? b ] ^ NAFLD 0 2 _? b [4 10,17,23,24] ` )^ _ ` P Z _! \ ^1a b,> c :(1)A) X$ ( )^ _`) R U;(2)U F ; (3) < X $, ALT AST GGT \ H <;(4)HBsAg( \N HBV DNA) HCV( \ N HCV RNA) );(5) TG HDL C I RC DE R ;(6)FPG P %C, FPG 5 6 mmol / L G N \ Q 75 g (oral glucose tolerance test,og TT) 3. ' TU NAFLD N,' X$ [4 10,17,23,24] :(1) FPG `abf & ' IR X (homeostatic model assessment,ho MA IR), OGTT U `ab \;(2)U 5 C C H C a ;(3) R D%b C <! 3,! P N Y 0 J C! ;(4) & Y 5 6 R P;(5)! 56 #, ]# \,\ CT ;(6) 2 a J NE ) NE P;(7)XY!S 9] NAFL _ NASH U NAFLD \ 3, ] NAFLD TUK> ;!S 4. [!S & ' ':(1) > TU \ V W 9 2 T U N;(2)a 6\! P OA! P N;(3) T U N; (4)5' c 4 ( D ) N;(5) N +! \^ c [4,9,17,23,24]! S _ ' F c X VW,! &' $ N?b 5. [ 'Q c: IR K 4! _`a b F! IR X ;! TG ; X 4& CT U)R ; / CT R ; ' NAFL _ NASH &'! P, R<b b X$ \56 [4 10,17,23,24] 4! ' NAFLD 0G N! W' NAFL 3,VW NAFLD c$ IR, V Z, N S^ F S; c$ Q! R S 0? NASH!,NASH N ;! 6, Q! P! 0 X E X [4 10,17,23 25] ]^ , S 3 T:K # S3T, VW (Ⅲ), D b,c D A ; Q ~ kj(500 ~ );, [I IR <, Q RS TRS 0 a ; a R, 2 4 O,F Q 150 min [4 10,17,23,26 28] K>; a\ D )^ a' NAFLD K [4,9] (Ⅱ 1,Ⅱ 2) 2. )^, Q_`: 0CD NAFLD N S3T 6 ~ 12 )^ I 5% O, [ J 2 T

4 486! "# Chin J Gastroenterol Hepatol,Jun 2010,Vol 19,No 6 c [4 10,17,23,27] (Ⅱ 1,Ⅱ 2)! Y, C D E N C V W % ' O P : C [4 10,17,23,24,27] (Ⅱ 1) NAFLD N < = >! K> )^ (Ⅱ 1), ] a% C C U\ )^ a \ [4,9,10] 3. IR, VW: ;,' VW O?b 0E(Ⅰ) 2! ( < ' 3 > Ob)! #U! P P,NAFLD N' UZ Y b )!" `ab "( J # $ F $ F) %, I U V R V W R P [4 10,17,23,24,29] (Ⅲ) X NAFLD N < =>! M,&a \ [4 10,17,23,24] (Ⅰ,Ⅱ 1,Ⅱ 2,Ⅱ 3) 4. Q a a! (Ⅲ):NAFLD ] NASH N )^,' I 8 C, ( F, 1a! ^, Z ' a! \ ],$' Z [10] 5.! V! P:! NAFLD V M W 9 a [4 10,17,23,24],c 0 NAFLD / NASH N> Z X VW,! M ( V W ' [10,16,24] P (Ⅲ):(1)! T NASH N;(2) ' 2! ( ) 6\! PN, 0 < 2 NAFLD N;(3))?a' *X! + VW34 N, VW D - < N;(4) 0Y! -E!N [ SR % $,, R D -. b( )? / H " 0 b E 1 DH S C H? 1 ~ 2 ^ (Ⅱ 1,Ⅱ 2,Ⅱ 3),W D K > ; 6 ~ 12 O [10] (Ⅲ) 6. W! P 0XE: ;, V! P/ U! 0 XE(Ⅲ) NASH 0!! P NAFLD 0 X! N '! V W [9,10,17,23,24] (Ⅱ 2)! U 1 & ' O?b 0E, 9;a V W, Q NAFLD X N B [9,10,17,23,24] ] 5 1. K a 2, 3 4 N R )^ _` _ S^ 56X$ 78, )P F9 [9,10] (Ⅲ) 2. W% U; &' V <! P0 #, : ;R VW34;R! - ' c N [4,9,10,17,23,24] (Ⅲ) 3. NAFLD N )^ _` U! R, \! D K O4&56 [6,9] (Ⅲ) [ N P0 a TWXM, \ Z! P 0XE(! Y ) [9,10,13,25,29] (Ⅲ) (, ) +: ( ); ( F); ([ \ W); (7 ) +: (, ); ( 0); \ 7 (C ); 2 ();@ (7 ); ( ); 2 (GS ); ( ); $ ( M );! " ( #-); $% (R );& ' < ( ); (= ); ( ); ( ) * +, - (. /) [1] Farrell GC,Larter CZ. Nonalcoholic fatty liver disease:from steatosis to cirrhosis [J]. Hepatology,2006,43(2 Suppl 1):S99 S112. [2] de Alwis NM,Day CP. Non alcoholic fatty liver disease:the mist grad ually clears [J]. J Hepatol,2008,48 Suppl 1:S104 S112. [3] Fan JG,Farrell GC. Epidemiology of non alcoholic fatty liver disease in China [J]. J Hepatol,2009,50: [4] Farrell GC,Chitturi S,Lau GK,et al. Guidelines for the assessment and management of non alcoholic fatty liver disease in the Asia Pacific region:executive summary [J]. J Gastroenterol Hepatol,2007,22:

5 [5] American Gastroenterological Association. American Gastroenterological Association medical position statement:nonalcoholic fatty liver disease [J]. Gastroenterology,2002,123: [6] Grattagliano I,Portincasa P,Palmieri VO,et al. Managing nonalco holic fatty liver disease:recommendations for family physicians [J]. Can Fam Physician,2007,53: [7] Eckel RH,Grundy SM,Zimmet PZ. The metabolic syndrome [J]. Lancet,2005,365: [8] Cohen DE,Anania FA,Chalasani N,et al. An assessment of statin safety by hepatologists [J]. Am J Cardiol,2006,97:77C 81C. [9] Vuppalanchi R,Chalasani N. Nonalcoholic fatty liver disease and non alcoholic steatohepatitis:selected practical issues in their evaluation and management [J]. Hepatology,2009,49: [10] Zeng MD,Fan JG,Lu LG,et al. Guidelines for the diagnosis and treatment of nonalcoholic fatty liver diseases [J]. J Dig Dis,2008, 9: [11] Lok AS,McMahon BJ;Practice Guidelines Committee,American As sociation for the Study of Liver Diseases (AASLD). Chronic hepatitis B:update of recommendations [J]. Hepatology,2004,39: [12] Angulo P. GI epidemiology:nonalcoholic fatty liver disease [J]. Ali ment Pharmacol Ther,2007,25: [13] Fan JG,Saibara T,Chitturi S,et al. What are the risk factors and settings of non alcoholic fatty liver disease in Asia Pacific [J]?J Gas troenterol Hepatol,2007,22: [14] Cheung O,Sanyal AJ. Hepatitis C infection and nonalcoholic fatty liver disease [J]. Clin Liver Dis,2008,12: [15] Fan JG,Chitturi S. Hepatitis B and fatty liver:causal or coincidental [J]?J Gastroenterol Hepatol,2008,23: [16] Fan JG. Strengthen the management of chronic viral hepatitis patients with fatty liver [J]. Zhonghua Ganzangbing Zazhi,2009,17: \ \! 0RS! TU_VW[J].! "#,2009,17: [17] Torres DM,Harrison SA. Diagnosis and therapy of nonalcoholic steatohepatitis [J]. Gastroenterology,2008,134: [18] Fan JG. Impact of non alcoholic fatty liver disease on accelerated met abolic complications [J]. J Dig Dis,2008,9: [19] Bugianesi E. Nonalcoholic fatty liver disease (NAFLD)and cardiac lipotoxicity:another piece of the puzzle [J]. Hepatology,2008,47: 2 4. [20] Kleiner DE,Brunt EM,Van Natta M,et al. Design and validation of a histological scoring system for nonalcoholic fatty liver disease [J]. Hepatology,2005,41: [21] Loomba R,Sirlin CB,Schwimmer JB,et al. Advances in pediatric nonalcoholic fatty liver disease [J]. Hepatology,2009,50: [22] Fan JG,Peng YD. Metabolic syndrome and non alcoholic fatty liver disease:asian definitions and Asian studies [J]. Hepatobiliary Pan creat Dis Int,2007,6: [23] Ali R,Cusi K. New diagnostic and treatment approaches in non alco holic fatty liver disease (NAFLD)[J]. Ann Med,2009,41: [24] Fan JG. Relationship between diabetes and liver disease and strategy for its diagnosis and treatment [J]. Zhonghua Tangniaobing Zazhi, 2009,1: _! T V "[J]. " #,2009,1: [25] Fan JG,Farrell GC;Asia Pacific working party for prevention of hep atocellular carcinoma. Prevention of hepatocellular carcinoma in non viral related liver diseases [J]. J Gastroenterol Hepatol,2009,24: [26] Bellentani S,Dalle Grave R,Suppini A,et al. Behavior therapy for nonalcoholic fatty liver disease:the need for a multidisciplinary ap proach [J]. Hepatology,2008,47: [27] Hainer V,Toplak H,Mitrakou A. Treatment modalities of obesity: what fits whom [J]?Diabetes Care,2008,31 Suppl 2:S269 S277. [28] Zivkovic AM,German JB,Sanyal AJ. Comparative review of diets for the metabolic syndrome:implications for nonalcoholic fatty liver dis ease [J]. Am J Clin Nutr,2007,86: [29] Riley P,Al Bakir M,O'Donohue J,et al. Prescribing statins to pa tients with nonalcoholic fatty liver disease:real cardiovascular benefits outweigh theoretical hepatotoxic risk [J]. Cardiovasc Ther,2009, 27: