自身免疫性肝炎与药物性肝损伤：鉴别诊断和处理苗琪马雄[关键词]肝炎，自身免疫性;肝炎，慢性，药物性;鉴别诊断；治疗Differentialdiagnosisandtherapyforautoimmunehepatitisanddrug-inducedliverinjuryMIAOQiMAXiong[Keywords]Hepatitis,autoimmune；Hepatitis,chronic,drug-Induced；Differentialdiagnosis；Therapy[Firstauthor'saddress]DepartmentofGastroenterology,RenjiHospital,ShanghaiJiaotongUniversitySchoolofMedicineShanghaiInstituteofDigestiveDisease,Shanghai200001,ChinaCorrespondingauthor:MAXiong,Email:maxiongmd@hotmail.com自身免疫性肝炎(AIH)是由异常自身免疫反应介导的肝实质炎症性病变，多发于女性，以高丙种球蛋白血症、血清自身抗体阳性和对免疫抑制剂治疗应答为特点。药物性肝损伤(drug-inducedliverinjury,DILI)是与用药相关的肝功能损伤，同样多见于女性，有时可出现自身抗体阳性，严重病例需免疫抑制剂治疗。两者究竟存在怎样的关系，如何在初诊时予以鉴别和适当治疗是临床医生需要重视的问题。@@一、AIH和DILI的关系@@在临床工作中存在这样的现象：DILI患者恢复后再次使用相同或相似的药物可出现AIH样表现。Lucena等[1]从西班牙药物性肝损中心选取9例两次出现DILI的患者(9/742)，其中8例第二次肝损伤的类型和第一次相同（肝细胞型为主），4例患者两次肝损伤前后使用药物的结构相似，2例作用靶点相似。10.3760/cma.j.issn.1007-3418.2012.05.003作者单位：200001上海交通大学医学院附属仁济医院消化科上海市消化疾病研究所激素对两者均有@@[1]LucenaMI,KaplowitzN,HallalH,etal.Recurrentdrug-inducedliverinjury(DILI)withdifferentdrugsintheSpanishregistry:thedilemmaoftherelationshiptoautoimmunehepatitis.JHepatol,2011,55:820-827.@@[2]AlvarezF,BergPA,BianchiFB,etal.Internationalautoimmunehepatitisgrouprepot:reviewofcriteriafordiagnosisofautoimmunehepatitis.JHepatol,1999,31:929-938.@@[3]HennesEM,ZeniyaM,CzajaAJ,etal.Simplifiedcriteriaforthediagnosisofautoimmunehepatitis.Hepatology,2008,48:169-176.@@[4]Weiler-NormannC,SchrammC.Druginducedliverinjuryanditsrelationshiptoautoimmunehepatitis.JHepatol,2011,55:747-749.@@[5]CzajaAJ.Drug-inducedautoimmune-likehepatitis.DigDisSci,2011,56:958-976.@@[6]BjōrnssonE,TalwalkarJ,TreeprasertsukS,etal.Drug-inducedautoimmunehepatitis:clinicalcharacteristicsandprognosis.Hepatology,2010,51:2040-2048.@@[7]BogdanosDP,Mieli-VerganiG,VerganiD.Autoantobodiesandtheirantigensinautohmmunehepatitis.SeminLiverDis,2009,29:241-253.@@[8]LecoeurS,AndréC,BeaunePH.Tienilicacid-inducedautoimmunehepatitis:anti-liverand-kidneymicrosomaltype2autoantibodiesrecognizeathree-siteconformationalepitopeoncytochromeP4502C9.MolPharmacol,1996,50:326-333.@@[9]ZimmermanHJ.Drug-inducedliverdisease.ClinLiverDis,2000,4:73-96.@@[10]EfeC,PurnakT,OzaslanE,etal.Drug-inducedautoimmunehepatitiscausedbyanti-tumornecrosisfactorαagents.Hepatplogy,2010,52:2246-2247.@@[11]vonKalckreuthV,LohseAW,SchrammC.Unmaskingautoimmunehepatitisunderimmunomodulatorytreatmentofmultiplesclerosisnotonlybetainterferon.AmJGastroenterol,2008,103:2147-2148.@@[12]WatkinsPB,SeeffLB.Drug-inducedliverinjury:summaryofasingletopicclinicalresearchconference.Hepatology,2006,43:618-631.@@[13]FontanaRJ,SeeffLB,AndradeRJ,etal.Standardizationofnomenclatureandcausalityassessmentindrug-inducedliverinjury:.summaryofaclinicalresearchworkshop.Hepatology,2010,52:730-742.@@[14]SuzukiA,BruntEM,KleinerDE,etal.Theuseofliverbiopsyevaluationindiscriminationofidiopathicautoimmunehepatitisversusdrug-inducedliverinjury.Hepatology,2011,54:931-939.@@[15]LewisJH.Diagnosis:liverbiopsydifferentiatesDILIfromautoimmunehepa...
