Article(id=1198558170584023841, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1198558165093675863, articleNumber=null, orderNo=null, doi=10.11855/j.issn.0577-7402.0363.2024.0625, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=research-article, receivedDate=1710950400000, receivedDateStr=2024-03-21, revisedDate=null, revisedDateStr=null, acceptedDate=1713974400000, acceptedDateStr=2024-04-25, onlineDate=1763688136001, onlineDateStr=2025-11-21, pubDate=1724774400000, pubDateStr=2024-08-28, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1763688136001, onlineIssueDateStr=2025-11-21, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1763688136001, creator=13701087609, updateTime=1763688136001, updator=13701087609, issue=Issue{id=1198558165093675863, tenantId=1146029695717560320, journalId=1189873630562394117, year='2024', volume='49', issue='8', pageStart='855', pageEnd='976', issueExtLink='null', onlineDate='null', pubDate='null', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=0, createTime=1763688134691, creator=13701087609, updateTime=1763689174168, updator=13701087609, preIssue=null, nextIssue=null, ext={EN=IssueExt(id=1198562525043327039, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1198558165093675863, language=EN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=), CN=IssueExt(id=1198562525043327040, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1198558165093675863, language=CN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=)}, issueFiles=null}, startPage=952, endPage=958, ext={EN=ArticleExt(id=1198558170881819438, articleId=1198558170584023841, tenantId=1146029695717560320, journalId=1189873630562394117, language=EN, title=Advances in diagnosis and treatment of adult hemophagocytic syndrome, columnId=1190243275882729994, journalTitle=Medical Journal of Chinese People’s Liberation Army, columnName=Review, runingTitle=null, highlight=null, articleAbstract=

Hemophagocytic syndrome (HPS), also known as hemophagocytic lymphohistiocytosis (HLH), is a rare and highly malignant hematologic disease with a poor prognosis. It can be divided into two categories: primary HLH and secondary HLH. HLH is characterized by a large number of abnormal immune cells that continuously activate and regulate out of control, leading to systemic inflammatory factor storm and multiple organ failure. Clinical manifestations mainly include persistent malignant hyperthermia, pancytopenia, hepatosplenomegaly, and hemophagocytosis in tissues and organs. The pathogenesis of adult HLH is complex, with rapid onset and rapid disease progression, and the fatality rate remains high. The main causes of death in HLH patients are multiple organ failure, abnormal coagulation and septic shock. Due to the specificity of HLH and the lack of effective understanding of the severity and prognosis in clinical practice, some HLH patients are misdiagnosed or overlooked, missing the best opportunity for diagnosis and treatment. Therefore, this review systematically explores and discusses the latest diagnostic and treatment progress of adult HLH, aiming to provide reference for clinical diagnosis, treatment and prognosis assessment of HLH.

, correspAuthors=Jian-Zhen Shen, authorNote=null, correspAuthorsNote=
E-mail:
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作为临床较罕见且预后差的恶性血液病,噬血细胞综合征(HPS)亦被称为噬血细胞性淋巴组织细胞增生症(HLH),可分为原发性(遗传性)HLH和继发性(获得性)HLH两类,其特征为大量异常的免疫细胞持续激活与调节失控,进而导致全身性炎性因子风暴和多器官衰竭,临床表现主要为持续恶性高热、全血细胞减少、肝脾大和组织器官发生噬血现象等。成人HLH致病诱因复杂,起病急骤,病情进展迅速,病死率居高不下,多器官衰竭、出凝血异常及脓毒性休克是患者死亡的重要原因。由于疾病的特殊性以及临床实践中对病情严重性和预后判断缺乏有效认识,导致部分HLH患者被漏诊、误诊,继而错过最佳诊疗时机。本文针对成人HLH诊断与治疗的新进展进行系统性综述,旨在为HLH的临床诊疗、预后评估等提供借鉴与参考。

, correspAuthors=沈建箴, authorNote=null, correspAuthorsNote=
沈建箴,E-mail:
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刘彦权,医学博士,主治医师,主要从事恶性血液病的科研与临床以及高等医学教育研究

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刘彦权,医学博士,主治医师,主要从事恶性血液病的科研与临床以及高等医学教育研究

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刘彦权,医学博士,主治医师,主要从事恶性血液病的科研与临床以及高等医学教育研究

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Ther Apher Dial, 2022, 26(5): 1023-1029., articleTitle=Prognostic death factors in secondary hemophagocytic lymphohistiocytosis children with multiple organ dysfunction syndrome receiving continuous renal replacement therapy: A multicenter prospective nested case-control study, refAbstract=null)], funds=[Fund(id=1198578975422378701, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198558170584023841, awardId=null, language=EN, fundingSource=National Clinical Key Specialty Construction Project(Min Medical Administration 2021-76), fundOrder=null, country=null), Fund(id=1198578975489487569, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198558170584023841, awardId=null, language=CN, fundingSource=国家临床重点专科建设项目(闽卫医政2021-76号), fundOrder=null, country=null), Fund(id=1198578975569179348, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198558170584023841, awardId=2020Y2006, language=EN, fundingSource=Project of Fujian 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HLH. 噬血细胞性淋巴组织细胞增多症(噬血细胞综合征);SF. 铁蛋白;TG. 三酰甘油;FIB. 纤维蛋白原;sCD25. 可溶性白细胞介素-2受体;NK. 自然杀伤;3/8、4/8、5/8分别指符合HLH-2004版诊断标准8项指标中的3项、4项和5项

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成人噬血细胞综合征诊疗研究进展
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刘彦权 1 , 陈晓君 2 , 曾敏娟 3 , 沈建箴 4, *
解放军医学杂志 | 综述 2024,49(8): 952-958
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解放军医学杂志 | 综述 2024, 49(8): 952-958
成人噬血细胞综合征诊疗研究进展
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刘彦权1, 陈晓君2, 曾敏娟3, 沈建箴4, *
作者信息
  • 1广东医科大学第一临床医学院血液内科,广东东莞 523808
  • 2莆田学院附属医院血液科,福建莆田 351100
  • 3广东医科大学基础医学院解剖学教研室,广东东莞 523808
  • 4福建医科大学附属协和医院血液科,福建福州 350001
  • 刘彦权,医学博士,主治医师,主要从事恶性血液病的科研与临床以及高等医学教育研究

通讯作者:

沈建箴,E-mail:
Advances in diagnosis and treatment of adult hemophagocytic syndrome
Yan-Quan Liu1, Xiao-Jun Chen2, Min-Juan Zeng3, Jian-Zhen Shen4, *
Affiliations
  • 1Department of Hematology, the First School of Clinical Medicine, Guangdong Medical University, Dongguan, Guangdong 523808, China
  • 2Department of Hematology, the Affiliated Hospital of Putian University, Putian, Fujian 351100, China
  • 3Department of Anatomy, School of Basic Medicine, Guangdong Medical University, Dongguan, Guangdong 523808, China
  • 4Department of Hematology, Fujian Medical University Union Hospital, Fuzhou, Fujian 350001, China
出版时间: 2024-08-28 doi: 10.11855/j.issn.0577-7402.0363.2024.0625
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作为临床较罕见且预后差的恶性血液病,噬血细胞综合征(HPS)亦被称为噬血细胞性淋巴组织细胞增生症(HLH),可分为原发性(遗传性)HLH和继发性(获得性)HLH两类,其特征为大量异常的免疫细胞持续激活与调节失控,进而导致全身性炎性因子风暴和多器官衰竭,临床表现主要为持续恶性高热、全血细胞减少、肝脾大和组织器官发生噬血现象等。成人HLH致病诱因复杂,起病急骤,病情进展迅速,病死率居高不下,多器官衰竭、出凝血异常及脓毒性休克是患者死亡的重要原因。由于疾病的特殊性以及临床实践中对病情严重性和预后判断缺乏有效认识,导致部分HLH患者被漏诊、误诊,继而错过最佳诊疗时机。本文针对成人HLH诊断与治疗的新进展进行系统性综述,旨在为HLH的临床诊疗、预后评估等提供借鉴与参考。

噬血细胞综合征  /  恶性血液病  /  诊断与鉴别  /  治疗  /  预后

Hemophagocytic syndrome (HPS), also known as hemophagocytic lymphohistiocytosis (HLH), is a rare and highly malignant hematologic disease with a poor prognosis. It can be divided into two categories: primary HLH and secondary HLH. HLH is characterized by a large number of abnormal immune cells that continuously activate and regulate out of control, leading to systemic inflammatory factor storm and multiple organ failure. Clinical manifestations mainly include persistent malignant hyperthermia, pancytopenia, hepatosplenomegaly, and hemophagocytosis in tissues and organs. The pathogenesis of adult HLH is complex, with rapid onset and rapid disease progression, and the fatality rate remains high. The main causes of death in HLH patients are multiple organ failure, abnormal coagulation and septic shock. Due to the specificity of HLH and the lack of effective understanding of the severity and prognosis in clinical practice, some HLH patients are misdiagnosed or overlooked, missing the best opportunity for diagnosis and treatment. Therefore, this review systematically explores and discusses the latest diagnostic and treatment progress of adult HLH, aiming to provide reference for clinical diagnosis, treatment and prognosis assessment of HLH.

hemophagocytic syndrome  /  malignant hematological diseases  /  diagnosis and differentiation  /  treatment  /  prognosis
刘彦权, 陈晓君, 曾敏娟, 沈建箴. 成人噬血细胞综合征诊疗研究进展. 解放军医学杂志, 2024 , 49 (8) : 952 -958 . DOI: 10.11855/j.issn.0577-7402.0363.2024.0625
Yan-Quan Liu, Xiao-Jun Chen, Min-Juan Zeng, Jian-Zhen Shen. Advances in diagnosis and treatment of adult hemophagocytic syndrome[J]. Medical Journal of Chinese People’s Liberation Army, 2024 , 49 (8) : 952 -958 . DOI: 10.11855/j.issn.0577-7402.0363.2024.0625
作为一种因获得性免疫异常或遗传性缺陷等因素所致的以全身性炎性因子风暴与暴发性炎症反应为主要特征的恶性血液病,噬血细胞综合征(hemophagocytic syndrome,HPS)又被称为噬血细胞性淋巴组织细胞增生症(hemophagocytic lympho-histiocytosis,HLH),其本质是CD8+ T淋巴细胞、自然杀伤(natural killer,NK)细胞以及单核-巨噬细胞等免疫原性细胞群失衡诱导的一种致命性过度炎症状态[1-2]。HLH在1939年由Scot等[3]率先报道,当时命名为组织细胞髓质网状细胞增多症;Farquhar等[4]在1952年根据HLH的疾病特点将其改名为家族性噬血细胞性网状细胞增生症;直至1991年,国际组织细胞学会提出了“噬血细胞性淋巴组织细胞增生症”这一命名[5],并沿用至今。由于HLH的病情及预后错综复杂,若对其认识不足易延误临床诊疗并导致极高的病死率,正确诊断并及早鉴别HLH在血液内科及感染科临床实践中具有重要的现实意义。
作为一种遗传性或获得性免疫缺陷所致的过度炎症反应综合征,HLH通常被分为两类,即原发性HLH(primary HLH,pHLH)与继发性HLH(secondary HLH,sHLH),临床以sHLH为多见[6]。pHLH多发生于儿童,常伴随遗传性细胞毒性功能丧失、炎症活化相关基因缺陷(突变),根据基因缺陷的特点,又可将pHLH细分为家族性HLH、免疫缺陷综合征相关HLH、X连锁淋巴增生性疾病及EB病毒(Epstein-Barr virus,EBV)驱动型HLH[7-10]。而sHLH一般见于成人,与恶性肿瘤、风湿免疫性疾病、病毒感染、器官移植、代谢性疾病等各种潜在疾病以及妊娠、嵌合抗原受体T细胞免疫治疗、药物或化学毒理诱发等多方面的因素密切相关[11-13]。随着分子生物学检测技术的不断革新,目前研究表明sHLH也可能存在一定的分子生物学异常。
由于HLH是一类病理性炎症反应综合征,临床症状或体征缺乏特异性,但不明原因的持续恶性高热、血细胞减少以及肝脾肿大或肝功能异常被视为“HLH三联征”[14]。HLH的特征为CD8+ T淋巴细胞、NK细胞以及单核-巨噬细胞等免疫细胞异常激活且增殖失控,诱发严重的全身性免疫炎症反应和细胞因子风暴,进而导致多器官衰竭[15]。成人HLH起病急、进展快、病情凶险,病死率极高。由于HLH临床表现缺乏特异性,潜在的致病因素难以鉴别与排除,故极易误诊、漏诊,进而导致诊疗延误,使患者错失最佳诊治时机,多数HLH患者在3个月内死亡,中位生存时间仅2个月左右甚至更短[16-17]
目前,临床实践中依旧沿用以实验室检查辅以临床表现的HLH-2004版诊断标准[18-19]。符合以下2条标准中任何一条即可诊断为HLH。(1)分子生物学检测结果诊断符合HLH:存在目前已知的HLH相关致病基因,如穿孔素1(perforin 1,PRF1)、unc-13同源物D(unc-13 homolog D,UNC13D)、突触融合蛋白11(syntaxin 11,STX11)、突触融合蛋白结合蛋白2(syntaxin binding protein 2,STXBP2)、Rab GTP酶家族成员27A(Rab GTPase family member 27A,Rab27a)、溶酶体运输调节蛋白(lysosomal trafficking regulator,LYST)、含SH2域蛋白1A(SH2 domain containing 1A,SH2D1A)、X-连锁细胞凋亡抑制因子(X-linked inhibitor of apoptosis,XIAP/BIRC4)、IL2诱导型T细胞激酶(IL2 inducible T-cell kinase,ITK)、衔接因子相关蛋白复合体3β1(adaptor related protein complex 3 beta 1,AP3β1)、镁转运蛋白1(magnesium transporter 1,MAGT1)、人CD27分子(Homo sapiens CD27 molecule,CD27)等致病性缺陷或突变。(2)符合以下8项指标中任何5项或以上:①发热。体温>38.5 ℃,持续>7 d。②脾大。③外周血细胞减少(累及二系或三系)。血红蛋白(hemoglobin,HGB)<90 g/L,血小板(platelet,PLT)<100×109/L,中性粒细胞(neutrophil,NEU)<1.0×109/L且非骨髓造血功能降低所致。④高甘油三酯(triglyceride,TG)血症和(或)低纤维蛋白原(fibrinogen,FIB)血症。TG>3 mmol/L或高于同龄患者3个标准差,FIB<1.5 g/L或低于同龄患者3个标准差。⑤在骨髓、肝脏、脾脏或淋巴结等组织或器官中发现噬血现象。⑥NK细胞活性降低或缺失。⑦血清铁蛋白(serum ferritin,SF)升高(≥500 μg/L)。⑧可溶性白细胞介素-2受体(sCD25)升高(≥2400 U/ml)。
值得注意的是,HLH亦可累及中枢神经系统(CNS),即出现CNS受累性HLH(central nervous system-HLH,CNS-HLH),可为HLH患者首发的临床表现,亦可出现在HLH病程之中[20-21]。CNS-HLH的诊断标准如下。(1)临床症状或体征:一般表现为异常的精神和(或)神经系统症状(如易激惹、惊厥、癫痫、意识改变、共济失调、脑膜刺激征、偏瘫等)。(2)CNS影像学改变:头颅MRI示脑实质或脑膜异常。(3)脑脊液(cerebrospinal fluid,CSF)异常:CSF中细胞增多或伴蛋白水平升高。当HLH患者出现上述一项或多项异常时,应考虑CNS-HLH。所有疑似CNS-HLH的患者均应完善头颅影像学检查、腰椎穿刺CSF检查等[22]。但需要注意的是,以CNS症状起病的原发性HLH临床表现通常不典型,少数原发性HLH患者以难以控制的脑白质病变为主要临床表现而就诊于神经内科,而淋巴造血系统症状及HLH相关实验室检查指标等变化不明显,缺乏特异性,极易漏诊、误诊。
如前所述,由于HLH临床表现缺乏特异性,不明原因的持续恶性高热(>38.5 ℃、持续>7 d)、血细胞减少(两系及以上)、肝脾肿大或肝功能异常被视为“HLH三联征”[23]。当患者出现上述临床症状或异常体征时,应怀疑HLH的可能。
所有可疑HLH的患者均应积极完善HLH确诊相关检查[14,24]:首先,尽管TG>3.0 mmol/L是HLH-2004版的诊断标准之一,由于干扰因素多,敏感度和特异度较低,但当FIB<1.5 g/L时具有诊断意义。其次,发生噬血现象并非HLH诊断的必要条件。再次,NK细胞活性降低通常指NK细胞杀伤靶细胞的作用降低,不能单纯以NK细胞数量减少、比例降低等来评判。此外,国际组织细胞协会定义的sCD25水平升高是指sCD25≥2400 U/ml,而国内外研究认为sCD25≥6400 pg/ml是HLH的有效诊断指标[14]。最后,HLH相关细胞因子谱检测可有效提升HLH诊断的特异度和敏感度[25]。符合HLH-2004版诊断标准8项指标中的5项及以上时,即可诊断HLH,并应及早完善HLH病因学检查,而当患者仅符合4项甚至3项及以下标准(可疑HLH)时,应密切关注并监测病情变化,重复评估HLH诊断相关的指标。
目前SF≥500 μg/L是HLH重要的诊断标准之一且敏感度较高[26-27],但应当注意的是,SF<500 μg/L可能是HLH诊断的负性评价指标[28]。对HLH疑似病例建议首先进行SF水平检测,如显著升高,对诊断HLH具有重要价值,随后完善HLH确诊相关检查。而对于SF<500 μg/L的HLH疑似患者,应密切关注并监测其病情变化,并积极重复评估HLH诊断相关指标[14]
应详细询问患者的职业史(是否有化学毒物或放射性物质接触史),婚育史(是否近亲婚配),家族史,过敏史,有无发热、盗汗及体重下降,以及查体有无皮疹、出血或肝脾和淋巴结肿大等。详细了解特殊用药史、治疗史(如免疫治疗)、手术史(器官或造血干细胞移植)以及旅行或居住史。
基因测序为pHLH诊断的金标准[29-30],基因测序指征包括但不限于:(1)细胞毒功能检查、HLH相关致病基因检测已确诊异常者;(2)发病年龄<12岁或存在家族史者;(3)反复发作性HLH或难以明确病因的HLH患者。
(1)流式细胞术检测NK细胞及细胞毒性T淋巴细胞表面ΔCD107a可快速筛查与脱颗粒途径有关的pHLH[31-32]。(2)pHLH相关致病基因检测:UNC13D/Munc13-4、信号淋巴细胞活化分子相关蛋白(SLAM-associated protein,SAP)、PRF1XIAP及颗粒酶B(granzyme B,GZMB)等基因表达及蛋白功能检测可快速鉴别pHLH[33-34]
积极完善病毒[如EBV或人类免疫缺陷病毒(HIV)]、细菌、真菌及原虫感染等检测,病原学高通量测序技术(next generation sequencing,NGS)检测可协助诊断HLH感染病因[35-36]
积极完善正电子发射计算机断层扫描显像(positron emission tomography/computed tomography,PET-CT)或高分辨率CT等影像学检查、病理活检(如淋巴结活检)、骨髓穿刺活检(免疫分型、分子生物学及细胞遗传学检测)等,以鉴别及诊断肿瘤相关HLH[14,37-38]
风湿免疫性疾病相关HLH亦称为巨噬细胞活化综合征,其早期可表现为非感染性因素所致白细胞(WBC)、血小板(PLT)、FIB及C反应蛋白(C反应蛋白)水平升高,同时伴红细胞沉降率增快[39-40]。随着病情进展,炎症指标显著异常及血细胞进行性减少对HLH的诊断具有重要意义[14]。故对于高度怀疑HLH的患者,应积极完善血常规、免疫球蛋白、补体以及自身抗体等检查。HLH的诊断流程如图1所示。
HLH作为一种起病急骤、病情进展快的高致死性恶性血液病,及早采取妥善治疗是改善预后的关键。HLH的临床治疗通常分为2个阶段:(1)针对炎性因子风暴状态、控制HLH持续活化进展的诱导缓解性治疗;(2)纠正潜在免疫异常或功能缺陷、控制原发病以防治HLH复发的病因治疗。
目前临床实践中仍推荐HLH-1994版方案,其为成人HLH首选的诱导缓解性治疗方案[41]。HLH-1994版方案适用于各类型HLH的一线诱导缓解性治疗,经典8周诱导治疗含有依托泊苷(etoposide,VP-16)和地塞米松(dexamethasone,DEX),以及腰穿鞘内注射甲氨蝶呤(methotrexate,MTX)和DEX。HLH-1994版方案:第1~2周VP-16剂量150 mg/m2,2次/周;第3~8周VP-16剂量150 mg/m2,1次/周。第1~2周DEX剂量10 mg/(m2.d);第3~4周DEX剂量5 mg/(m2.d);第5~6周DEX剂量2.5 mg/(m2.d);第7~8周DEX剂量1.25 mg/(m2.d)。值得注意的是,VP-16还需基于年龄调整剂量:<15岁的HLH患者75~150 mg/m2;15~39岁的HLH患者75~100 mg/m2;>40岁的HLH患者50~75 mg/m2。此外,与后续2004版HLH治疗指南(HLH-2004版方案)不同,HLH-1994版方案在8周诱导缓解性治疗结束后加用环孢霉素A(cyclosporine A,CsA),而HLH-2004版方案则推荐在初始开启治疗时就联用CsA。需要注意的是,风湿免疫性疾病相关HLH及少数轻型HLH可单用糖皮质激素进行冲击治疗,而通过病原学检测明确为特殊病原体感染所致HLH者,在接受针对病原体感染的治疗后病情可获得控制,无须在治疗阶段应用细胞毒药物和免疫调节剂[14]
然而,前述“一线治疗”方案中的8周经典诱导缓解性治疗并非必须给予患者完整的8周治疗。对于大部分继发性HLH患者,临床上还需不断实时评估病情,及时中止HLH治疗决策,从而转向其明确的原发病治疗。故在初始诱导缓解性治疗2周后应及时进行疗效评估,未达部分缓解及以上疗效者应尽早开启挽救性治疗。而复发性HLH患者则应继续采用原方案或应用不同的挽救性治疗方案。HLH的挽救性治疗方案具体如下:
该化学治疗方案由脂质体多柔比星、VP-16和甲泼尼龙三药组合而成[42]。第1天起始剂量为:脂质体多柔比星25 mg/(m2.d);VP-16 100 mg/(m2.d)(需调整至年龄剂量);第1~3天甲泼尼龙2 mg/(kg.d),第4~14天甲泼尼龙0.2 mg/(kg.d)(风湿免疫性疾病相关HLH激素可高剂量维持)。上述方案每2周重复1次。而对于EBV相关HLH的治疗可采用DEP方案联合培门冬酶(或左旋门冬酰胺酶),培门冬酶推荐剂量为1800 U[14,43]
成人HLH患者芦可替尼使用剂量为10 mg,2次/d,亦可联合激素、HLH-1994版方案、DEP方案等,这些联用可能增强临床疗效[44-46]
依帕伐单抗初始剂量为每3天1 mg/kg,随后根据药代动力学或临床指标等逐步递增剂量至3 mg/kg、6 mg/kg,最大剂量原则上不超过10 mg/kg,治疗时间为8周,可根据病程及病情予以延长(准备造血干细胞移植)或缩短(一般<4周)[47-48]。依帕伐单抗亦可与激素(如地塞米松)联用,地塞米松推荐剂量为5~10 mg/(m2.d)[14]
新型细胞因子包括CD52单抗(阿伦单抗)[49]、γ干扰素(interferon-γ,IFN-γ)靶向抑制剂(伊帕伐单抗)[50]、IL-1受体拮抗剂(阿那白滞素)[51]、IL-6受体拮抗剂(托珠单抗)[52]等,可根据国内外临床实践经验及患者实际状况个性化选择和应用,必要时亦可进入临床试验。
维持治疗一般推荐用于尚无法进行异基因造血干细胞移植(allogeneic hematopoietic stem cell transplantation,allo-HSCT)的原发性HLH患者[14]。依照HLH-1994方案,维持治疗的方案为VP-16联合DEX[VP-16 150 mg/(m2.d),1次/2周;DEX 10 mg/(m2.d),维持3 d,1次/2周]。维持治疗方案可视临床病情予以实时调整,继发性HLH患者应在HLH缓解后及时转向原发病的针对性治疗。
对于HLH患者,其接受allo-HSCT的指征包括[14,53]:(1)已确诊为pHLH;(2)复发难治性HLH;(3)病情严重的CNS-HLH;(4)药物治疗疗效达到临床缓解。即使仅有单倍体供者,allo-HSCT亦可积极进行。应注意的是,风湿免疫性疾病相关HLH一般不建议进行allo-HSCT,而EBV相关HLH、淋巴瘤相关HLH患者可从allo-HSCT中获益,从而改善预后[54-55]。除需考虑HLA位点相合度、年龄、健康状况等因素外,HLH患者的供者筛选还需充分评估供者是否存在与受者关联的潜在疾病风险,如细胞毒功能(NK细胞活性、脱颗粒功能等)、HLH缺陷基因表达以及EBV-DNA等[56-57]
在病情及基础条件允许时,CNS-HLH患者应及早接受腰穿鞘内注射MTX和DEX。成人CNS-HLH患者推荐剂量一般为MTX 12 mg、DEX 5 mg,每周鞘内注射治疗持续至CNS恢复正常(临床及CSF指标)至少7 d[14,58]
HLH的支持治疗原则与HSCT的标准基本一致,即积极抗感染,同时鉴别HLH病情进展与感染,及时予以经验性广谱抗生素治疗[59]。与此同时,由于HLH患者自发性出血风险极高,应及时申请并输注PLT、新鲜冰冻血浆及凝血酶原复合物等,亦可应用促PLT生成药物,如重组人血小板生成素及艾曲泊帕等[14,60-62]。此外,由于严重炎症反应及药物毒性,HLH患者常出现多器官衰竭,需密切关注并监测患者脏器功能,必要时可予血浆置换、连续肾脏替代治疗(CRRT)等[63-64]
HLH患者在诱导缓解性治疗期间,推荐每2周评估1次疗效,疗效评价指标包括血细胞计数、SF、sCD25、TG、噬血现象以及意识水平(出现CNS-HLH者),具体包括[14,38]:(1)完全缓解。上述指标均恢复正常。(2)部分缓解。≥2项指标改善25%以上,个别指标需达以下标准:①sCD25下降1/3以上;②SF和TG下降25%以上;③未输血状态下,初诊时NEU<0.5×109/L的患者须上升100%并>0.5×109/L,而初诊时NEU为(0.5~2.0)×109/L的患者须上升100%并恢复正常;④谷丙转氨酶>400 U/L者,须下降50%以上。(3)无效,未达上述标准。
作为获得性免疫功能异常或遗传性缺陷所致的高致死性炎症反应综合征,HLH并非是独立的恶性血液病,而是复杂的临床条件及特殊机制引起的过度细胞炎性因子风暴。HLH起病急骤、进展快,同时致病机制尚不明确,临床表现具有高度异质性,极易发生漏诊、误诊。在临床实践中,通过遵循“疑似HLH-确诊HLH-追寻HLH病因”的三步法,可尽早识别并有效诊断HLH,这对于患者的后续治疗决策、预后转归至关重要。从分子生物学、免疫学等角度深入研究HLH的致病机制,探索高敏感度和特异度的临床诊断与治疗策略,是未来HLH基础与临床研究的重心,对于改善患者预后有着重要的现实意义。
  • 国家临床重点专科建设项目(闽卫医政2021-76号)
  • 福建省恶性血液病临床医学研究中心项目(2020Y2006)
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2024年第49卷第8期
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doi: 10.11855/j.issn.0577-7402.0363.2024.0625
  • 接收时间:2024-03-21
  • 首发时间:2025-11-21
  • 出版时间:2024-08-28
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  • 收稿日期:2024-03-21
  • 录用日期:2024-04-25
基金
National Clinical Key Specialty Construction Project(Min Medical Administration 2021-76)
国家临床重点专科建设项目(闽卫医政2021-76号)
Project of Fujian Clinical Medical Research Center for Hematologic Malignancies(2020Y2006)
福建省恶性血液病临床医学研究中心项目(2020Y2006)
作者信息
    1广东医科大学第一临床医学院血液内科,广东东莞 523808
    2莆田学院附属医院血液科,福建莆田 351100
    3广东医科大学基础医学院解剖学教研室,广东东莞 523808
    4福建医科大学附属协和医院血液科,福建福州 350001

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2种不同金属材料的力学参数

Family
属数
Number of
genus
种数
Number of
species
占总种数比例
Percentage of
total species (%)

Genus
种数
Number of
species
占总种数比例
Percentage of total
species (%)
鹅膏菌科Amanitaceae 2 11 5.26 鹅膏菌属 Amanita 10 4.78
小菇科 Mycenaceae 2 12 5.74 丝盖伞属 Inocybe 5 2.39
多孔菌科 Polyporaceae 8 14 6.70 蜡蘑属 Laccaria 5 2.39
红菇科 Russulaceae 3 23 11.00 小皮伞属 Marasmius 6 2.87
小菇属 Mycena 11 5.26
光柄菇属 Pluteus 5 2.39
红菇属 Russula 17 8.13
栓菌属 Trametes 5 2.39
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