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肝病相关血小板减少症的精准管理
DOI: 10.12449/JCH260902
利益冲突声明：本文不存在任何利益冲突。
作者贡献声明：石宛鑫负责撰写论文；闫慧文负责相关文献的检索、筛选与整理；杨志云负责拟定写作思路，指导文章框架结构，修改论文。石宛鑫、闫慧文对本文贡献等同，为共同第一作者。
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摘要: 肝病相关血小板减少症（HRT）是慢性肝病患者常见并发症，其发生发展涉及血小板生成减少、脾脏滞留、免疫介导破坏、血小板消耗增加及骨髓微环境异常等多种机制，可增加出血风险，并影响抗病毒治疗、抗肿瘤治疗及有创操作的顺利实施。近年来，随着基础研究及临床循证医学证据不断积累，HRT在发病机制、风险评估、诊断分层及治疗策略等方面取得了重要进展，精准管理理念逐渐由单纯提升血小板计数向病因导向、风险分层及个体化干预转变。本文结合近年来国内外最新研究进展，重点综述HRT发病机制的新认识、诊断与风险评估策略的优化，以及促血小板生成药物、免疫治疗、有创治疗和中西医结合治疗等管理策略的最新研究进展，以期为HRT的精准诊疗及临床决策提供参考，并为未来精准管理体系的建立提供依据。Abstract: Hepatopathy-related thrombocytopenia （HRT） is a common complication in patients with chronic liver disease， and the development and progression of HRT involve multiple mechanisms including decreased platelet production， splenic sequestration， immune-mediated destruction， increased platelet consumption， and abnormalities in the bone marrow microenvironment. HRT not only increases the risk of bleeding but also hampers the successful implementation of antiviral therapy， antitumor treatment， and invasive procedures. In recent years， with the accumulation of evidence from basic and clinical studies， significant advances have been achieved in the pathogenesis， risk assessment， diagnostic stratification， and therapeutic strategies for HRT， and the paradigm of precise management has gradually shifted from merely increasing platelet counts toward a cause-directed， risk-stratified， and individualized intervention approach. With reference to the latest research advances in China and globally， this article reviews the new insights into the pathogenesis of HRT， refinements in diagnostic and risk assessment strategies， and the latest research advances in management strategies such as thrombopoietic agents， immunotherapy， invasive therapies， and integrated traditional Chinese and Western medicine therapies， in order to provide a reference for precise diagnosis， treatment， and clinical decision-making in HRT and to lay a foundation for establishing a future precise management system.
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Key words:
- Liver Diseases /
- Thrombocytopenia /
- Therapeutics
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注： TPO，血小板生成素；rhTPO，重组人血小板生成素；rhIL-11，重组人白细胞介素11；TPO-RA，血小板生成素受体激动剂。
图 1 肝病相关血小板减少症的临床管理
Figure 1. Precision management of hepatopathy-related thrombopenia
表 1 HRT中血小板功能及整体止血功能检测技术
Table 1. Platelet function testing and global hemostatic assessment techniques in HRT
技术 检测原理/主要评估维度 在HRT中的潜在价值 主要局限及精准管理定位 LTA 光透射法检测激动剂诱导的血
小板聚集，反映血小板聚集功能评价血小板反应性，辅助解析血小板
数量与功能不一致的止血表型易受低PLT及前处理影响；主要用于功能评
价和机制研究，尚缺乏肝病特异性决策阈值Multiplate 全血阻抗法检测激动剂诱导的
血小板聚集，反映不同激活通路全血条件下评价血小板反应性，可补
充PLT对功能状态评估的不足结果受PLT影响，低PLT时解释受限；尚不
宜单独用于出血风险分层PFA 高剪切条件下检测血小板黏附、
激活和聚集，反映初级止血功能评价血小板-vWF依赖性止血，有助于
认识vWF升高对低PLT的代偿作用受PLT、Hct及vWF显著影响；适于辅助功能
评估，不宜作为独立风险预测指标TEG 全血黏弹性检测，动态反映凝血
启动、凝块强度及纤溶评估整体止血表型，可辅助围操作期
及出血患者的个体化止血管理MA等指标缺乏血小板特异性；更适于整体
凝血评估及目标导向治疗ROTEM 全血黏弹性检测，通过不同试验
体系评估凝血、凝块强度及纤溶可区分整体凝块强度与纤维蛋白原
贡献，辅助目标导向止血管理不能直接等同于血小板功能检测；主要用于
高风险操作、出血及肝移植等特定场景注：HRT，肝病相关血小板减少症；LTA，光透射聚集试验；Multiplate，多电极聚集分析；PFA，血小板功能分析仪；TEG，血栓弹力图；ROTEM，旋转血栓弹力测定；PLT，血小板计数；vWF，血管性血友病因子；Hct，血细胞比容；MA，最大振幅。
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