本文選題：CK18 + 慢性乙型肝炎��； 參考：《北京協(xié)和醫(yī)學(xué)院》2014年博士論文

【摘要】：研究背景 慢性乙型肝炎是長期以來威脅中國人民生命健康的一個重要的因素。反復(fù)的炎癥刺激引起肝纖維化,進(jìn)而出現(xiàn)不可逆轉(zhuǎn)的肝硬化,在此基礎(chǔ)上導(dǎo)致肝細(xì)胞肝癌的發(fā)生。中國的慢性乙型肝炎病毒攜帶者數(shù)量在一億左右,每年每十萬患者中因慢性肝炎肝硬化死亡者為24.5,因肝細(xì)胞肝癌死亡者為14.5。近年來,隨著預(yù)防接種的普及,乙型肝炎病毒的感染率有了明顯的下降,但仍處在相當(dāng)高的水平,在某些地區(qū)尤其居高不下。由于慢性乙型肝炎后肝硬化與肝癌的發(fā)生與進(jìn)展都很隱蔽,在確診時往往已經(jīng)難以挽回,導(dǎo)致肝硬化與肝癌的預(yù)后不良。因此,對慢性乙型肝炎后肝硬化、肝癌的早期診斷十分重要。 目前對慢性乙型肝炎后肝癌的早期診斷主要依靠血清AFP和肝臟超聲檢查的聯(lián)合應(yīng)用,取得了良好的效果。對更新更好的HCC血清標(biāo)記物的探索仍在繼續(xù),其中GP-73、GPC-3、AFP-L3展現(xiàn)出了較大的潛力。 然而,對于慢性乙型肝炎后肝硬化的早期診斷仍然是一個棘手的問題�，F(xiàn)有的針對肝纖維化與肝硬化病理生理過程的機(jī)制研究發(fā)現(xiàn)了一些有希望的血清標(biāo)記物,如PⅢNP、HA、LN等。但實際應(yīng)用研究發(fā)現(xiàn)即使是這些標(biāo)記物中診斷效能最好的幾種,也不是臨床上理想的選擇。目前對慢性乙型肝炎后肝纖維化與肝硬化的診斷金標(biāo)準(zhǔn)仍然是肝組織活檢。但由于肝組織活檢是有創(chuàng)檢查,不能廣泛應(yīng)用,患者在接受肝穿刺活檢時難免存在顧慮；而且難以反復(fù)取材監(jiān)測病情的動態(tài)變化,不能預(yù)測病情的發(fā)展。因此,研發(fā)一種新的診斷肝纖維化程度的血清學(xué)指標(biāo)成為目前迫切的需求。 CK18屬于細(xì)胞角蛋白家族,是正常細(xì)胞骨架的構(gòu)成成分,在多種上皮細(xì)胞中均有表達(dá)。CK18與慢性乙型肝炎后肝硬化以及肝癌的關(guān)系已經(jīng)得到了初步的關(guān)注,但CK18在這一病理生理過程中的具體意義以及和CK18對肝纖維化、肝硬化的診斷價值尚無系統(tǒng)研究報道。 其次,由于CK18屬于細(xì)胞骨架成分,在肝細(xì)胞被破壞時能夠釋放到血液中,因而從機(jī)制上分析,肝臟腫瘤患者和手術(shù)相關(guān)的肝損傷也可能引起血清CK18水平的變化。研究CK18在肝癌中的表達(dá)對于肝癌診斷、復(fù)發(fā)和預(yù)后觀察可能有潛在的意義；同樣,術(shù)前術(shù)后CK18水平的動態(tài)變化可能反映手術(shù)損傷,從而幫助判斷損傷程度和術(shù)后恢復(fù)進(jìn)程。以上兩方面研究內(nèi)容目前尚屬空白,在國際上還沒有相應(yīng)的文獻(xiàn)報道,其結(jié)果將有明顯的研究意義和臨床價值。 研究目的 (1)基于CK18在肝纖維化、肝硬化和肝癌中可能起到的作用,本研究首先應(yīng)明確血清CK18在慢性乙型肝炎后肝硬化合并肝癌的患者中是否較正常人群有所變化； (2)由于國內(nèi)大多數(shù)慢性乙型肝炎患者都存在程度不一的肝纖維化和肝硬化,本研究致力于闡明引起性乙型肝炎后肝硬化合并肝癌的患者血清CK18變化的主要原因是肝硬化還是肝癌,哪個因素是主要的,或兩者共同對于CK18血清學(xué)變化起到作用； (3)CK18屬于細(xì)胞骨架成分,在肝細(xì)胞破壞時能夠釋放入血,因此有理由認(rèn)為手術(shù)相關(guān)的肝細(xì)胞損傷能夠影響血清CK18的水平。本研究試圖探索CK18與手術(shù)相關(guān)肝損傷的關(guān)系,CK18水平能否反映肝臟損傷的程度以及術(shù)后康復(fù)的程度。 (4)手術(shù)相關(guān)肝損傷屬于急性肝損傷,而急性和慢性肝損傷的機(jī)制存在差別。本研究對比手術(shù)造成的急性肝損傷與肝纖維化、肝硬化及肝癌造成的慢性肝損傷,這兩種類型的肝損傷對血清CK18水平變化的影響的程度,以探究其機(jī)制上的差別,以及這種差別能否幫助臨床上治療肝硬化、肝癌的患者的過程中其疾病的進(jìn)程和預(yù)后的判斷。 實驗方法 2013年12月至2014年6月間,在北京協(xié)和醫(yī)院肝臟外科病房的手術(shù)病人中選取慢性乙型肝炎后肝硬化合并肝癌的患者作為研究組,肝海綿狀血管瘤患者作為對照組,其中慢性乙型肝炎后肝硬化合并肝癌的患者在4周內(nèi)未接受抗腫瘤治療。臨床信息包括患者年齡、性別、肝功能Child-Pugh評分、血清AFP、腫瘤大小、巴塞羅那分期。兩組患者分別在術(shù)前、術(shù)后第一天、術(shù)后第三天、術(shù)后第五天采集外周靜脈血,用M65和M30ELISA法分別測定其總CK18與CK18裂解片段的濃度。 結(jié)果 慢性乙型肝炎后肝硬化合并肝癌的患者術(shù)前的血清總CK18與CK18裂解片段水平均明顯高于對照組(總CK18:262.9±130.0U/L,對照組158.7±44.5U／L,P=0.038；CK18片段：145.1±69.6U／L,對照組81-6±15.2U／L,P=0.005),提示慢性乙型肝炎后肝硬化合并肝癌的患者的血清CK18水平確實較正常人群有明顯升高。 在術(shù)后第五天,慢性乙型肝炎后肝硬化合并肝癌的患者的血清總CK18與CK18裂解片段水平均降至接近正常值(總CK18：311.9±158.8U／L,對照組180.8±54.1U/L, P=0.078; CK18片段：103.5±32.0U／L,對照組82.9±8.0U／L,P=0.012),但由于樣本數(shù)量的限制,難以判斷肝硬化與肝癌對血清CK18的升高的影響的具體程度與相互關(guān)系。 CKl8在術(shù)前術(shù)后的動態(tài)變化呈現(xiàn)出與ALT類似的趨勢,在術(shù)后第一天達(dá)到峰值,然后開始逐漸下降,在術(shù)后第五天達(dá)到與術(shù)前相當(dāng)?shù)乃健Ｆ渲懈渭?xì)胞壞死產(chǎn)生的CK18與ALT有明顯的相關(guān)性(肝癌組相關(guān)系數(shù)為0.659,對照組為0.922)。而ALT在術(shù)后第五天時仍處在高于術(shù)前的水平(血管瘤組術(shù)前ALT11.±3.0U／L,術(shù)后第五天99.0±70.4U／L,P=0.01；肝癌組術(shù)前ALT19.8+8.0U／L,術(shù)后第五天188.1±119.4U／L,P=0),可能意味著CK18具有比ALT更加敏感、或有更短的半衰期,這個結(jié)論尚無文獻(xiàn)報道,是首次發(fā)現(xiàn)。 肝癌組術(shù)后第一天的總CK18(術(shù)前262.9±130.1U／L,術(shù)后第一天1286.9±984.3U／L,P=0.005)與肝細(xì)胞壞死產(chǎn)生的CK18(術(shù)前117.8±117.2U／L,術(shù)后第一天1065.6±831.9U／L,P=0.002)都顯著高于術(shù)前,而且升高的幅度非常大,這說明手術(shù)造成的急性肝損傷對血清CK18影響程度要遠(yuǎn)遠(yuǎn)大于肝硬化、肝癌造成的慢性肝損傷。 結(jié)論 (1)血清CK18在慢性乙型肝炎后肝硬化的患者中有明顯升高,這與研究設(shè)計時的預(yù)期結(jié)果一致,說明慢性乙型肝炎后肝硬化和肝癌確實能夠?qū)е略摷?xì)胞骨架結(jié)構(gòu)釋放入血液；在CK18升高的人群中,慢性乙型肝炎的影響因素也是一個需要考慮的問題,已有的研究已經(jīng)表明控制良好、無肝炎活動的慢性乙型肝炎病毒感染者,其血清CK18與正常人群相近,因此我們的研究認(rèn)為慢性乙型肝炎后肝硬化的患者中血清CK18的升高主要與肝臟損害相關(guān),可能可以作為慢性肝臟損害的潛在標(biāo)志物； (2)在慢性乙型肝炎后肝硬化合并肝癌的患者中,肝癌可能是引起血清CK18升高的因素中更主要的方面,本研究首次發(fā)現(xiàn)了這種趨勢,如果進(jìn)一步增加樣本數(shù),應(yīng)該能夠得到更有說服力的結(jié)果； (3)本研究首次證實了手術(shù)損傷能夠引起血清CK18升高,這與CK18在肝細(xì)胞破壞中的機(jī)制是相符合的。此外,本研究還發(fā)現(xiàn),血清CK18在術(shù)后第五天能夠降至接近術(shù)前水平,而ALT在術(shù)后第五天仍顯著高于術(shù)前水平；這提示CK18可能比ALT更加敏感,或者在血中代謝更快。這點(diǎn)尚無文獻(xiàn)報道,是首次發(fā)現(xiàn)。它的意義可能在于,在體內(nèi)如果沒有持續(xù)的肝細(xì)胞損傷而產(chǎn)生新的CK18產(chǎn)物,則血清中CK18水平能夠很快下降,這對于監(jiān)測疾病的活動情況、判斷用藥效果都有很大的幫助。 (4)對比慢性肝損傷,如肝纖維化和肝硬化,和急性肝損傷,如手術(shù)創(chuàng)傷,后者的血清CK18水平變化更大,可能暗示了在急性肝損傷過程中細(xì)胞骨架碎片釋放入血液的量更為顯著。這個結(jié)果對于臨床上治療肝硬化、肝癌的患者過程中對疾病的進(jìn)程和預(yù)后的判斷可能有重大意義。
[Abstract]:Background of the study

Chronic hepatitis B is an important factor which has long threatened the health of Chinese people . Repeated inflammatory stimulation causes liver fibrosis , which leads to the occurrence of liver cancer . In recent years , with the popularization of hepatitis B virus , the infection rate of hepatitis B virus has decreased significantly .

At present , the early diagnosis of liver cancer after chronic hepatitis B mainly depends on the combination of serum AFP and liver ultrasonography , and good results are obtained . The exploration of the better HCC serum markers is still continuing , in which GP - 73 , GPC - 3 , AFP - L3 exhibit greater potential .

However , the early diagnosis of liver cirrhosis after chronic hepatitis B is still a difficult problem . There are some promising serum markers , such as P鈪P , HA , LN , etc .
Therefore , it is urgent to develop a new serological index for the diagnosis of liver fibrosis .

CK18 belongs to the family of cytokeratins , which is a constitutive component of normal cellular skeleton , and has been expressed in various epithelial cells . The relationship between CK18 and chronic hepatitis B cirrhosis and liver cancer has been paid preliminary attention , but the specific significance of CK18 in this pathological process and the diagnosis value of CK18 in liver fibrosis and liver cirrhosis have not been reported .

Secondly , because CK18 belongs to the cytoskeletal component , it can be released into the blood when the liver cells are damaged . Therefore , it is possible to analyze the expression of CK18 in liver cancer , which may have potential significance for the diagnosis , recurrence and prognosis of liver cancer .
In the same vein , the dynamic changes of CK18 level before operation may reflect surgical injury , so as to help judge the degree of injury and the post - operative recovery process . The research contents of the above two aspects are still blank , and there are no corresponding literature reports in the world , and the results will have obvious research significance and clinical value .

Purpose of study

( 1 ) Based on the possible role of CK18 in liver fibrosis , liver cirrhosis and liver cancer , it should be clear whether serum CK18 changes in patients with liver cirrhosis and liver cancer after chronic hepatitis B .


( 2 ) Since most of the patients with chronic hepatitis B have a different degree of liver fibrosis and cirrhosis , the study is focused on the main reason for the change of serum CK18 in patients with cirrhosis and liver cirrhosis after induced hepatitis B is cirrhosis or liver cancer .


( 3 ) CK18 belongs to cytoskeletal component and can be released into blood when the liver cells are damaged . Therefore , it is reasonable to believe that the liver injury associated with surgery can influence the level of serum CK18 . This study attempts to explore the relationship between CK18 and surgical related hepatic injury , and whether CK18 can reflect the degree of liver injury and the degree of postoperative rehabilitation .

( 4 ) The hepatic injury associated with liver injury is an acute liver injury , and the mechanism of acute and chronic liver injury is different . The study compared the effect of acute liver injury with liver fibrosis , liver cirrhosis and liver cancer .

experimental method

From December 2013 to June 2014 , the patients with liver cirrhosis and liver cancer were selected as the control group . The patients with liver cirrhosis and liver cancer were treated with anti - tumor therapy within 4 weeks . The clinical information included age , sex , Child - A score , serum AFP , tumor size and Barcelona stage . The peripheral venous blood was collected on the first day of operation , the first day of operation , and the fifth day after operation .

Results

The serum total CK18 and CK18 cleavage levels were significantly higher in patients with liver cirrhosis after chronic hepatitis B than in the control group ( total CK18 : 262.9 鹵 31.0 U / L , 158.7 鹵 44.5U / L in the control group , P = 0.038 ) .
CK18 fragment : 145.1 鹵 69.6U / L , control group ( 81 - 6 鹵 15.2U / L , P = 0.005 ) , suggesting that serum CK18 levels in patients with liver cirrhosis after chronic hepatitis B were significantly higher than those in the normal population .

The serum total CK18 and CK18 cleavage levels of patients with liver cirrhosis and liver cirrhosis were reduced to near normal ( total CK18 : 31.9 鹵 158.8U / L , control group 180.8 鹵 54.1U / L , P = 0.078 ; CK18 fragment : 103.5 鹵 32.0U / L , control group 82.9 鹵 8.0U / L , P = 0.012 ) .

The dynamic changes of CK18 were similar to those of ALT before operation . The peak was reached on the first day of operation , then gradually decreased gradually , and the level of CK18 correlated with ALT was reached on the fifth day after operation . The correlation coefficient between CK18 and ALT in hepatocellular necrosis was 0.659 and 0.922 in the control group . ALT was still higher than preoperative level ( ALT11 . 鹵 3.0 U / L before operation ) at the fifth day after operation , and the fifth day after operation was 99.0 鹵 70.4 U / L , P = 0.01 ;
ALT19.8 + 8.0U / L , the fifth day after operation ( 188.1 鹵 119.4U / L , P = 0 ) , may mean that CK18 is more sensitive to ALT , or has a shorter half - life , which has not been reported in the literature for the first time .

The total CK18 ( 262.9 鹵 1.1U / L before operation , 126.9 鹵 984.3U / L at the first day of operation ) and CK18 ( 117.8 鹵 117.2U / L at the first day of operation ) were significantly higher than those of CK18 ( 117.6 鹵 117.2U / L , P = 0.002 ) after operation , which indicated that the effect of acute hepatic injury on serum CK18 was much higher than that in liver cirrhosis and liver cancer .

Conclusion

( 1 ) Serum CK18 was significantly elevated in patients with liver cirrhosis after chronic hepatitis B , which was consistent with the expected results at the time of study design , suggesting that cirrhosis and liver cancer after chronic hepatitis B did lead to release of the cytoskeletal structure into the blood ;
In the patients with elevated CK18 , the factors of chronic hepatitis B are also a need to consider . The existing research has shown that the control of the chronic hepatitis B virus infected with hepatitis B is similar to the normal population , so our study suggests that the elevation of serum CK18 in patients with liver cirrhosis after chronic hepatitis B is mainly related to liver injury , which may be a potential marker for chronic liver injury ;


( 2 ) In the patients with liver cirrhosis and liver cirrhosis after chronic hepatitis B , the liver cancer may be a more important aspect of the factors that cause the increase of serum CK18 . This trend is first found in the study , and if the number of samples is further increased , more convincing results should be obtained ;


( 3 ) For the first time , this study confirmed that surgical injury can cause the increase of serum CK18 , which is in agreement with CK18 ' s mechanism in liver cell destruction . In addition , the study also found that serum CK18 can be reduced to near pre - operative level in the fifth day after surgery , while ALT was still significantly higher in the fifth day after operation than preoperative level ;
This suggests that CK18 may be more sensitive to ALT , or more rapidly metabolized in the blood . This is the first finding . It is likely that the CK18 level in serum can be rapidly decreased if there is no persistent hepatocyte injury in the body , which can help monitor the activity of the disease and determine the effect of medication .

( 4 ) Compared with chronic liver injury , such as liver fibrosis and liver cirrhosis , and acute liver injury , such as surgical trauma , the level of serum CK18 in the latter is more significant , which may suggest that the amount of cellular debris released into the blood is more significant during acute liver injury .
【學(xué)位授予單位】：北京協(xié)和醫(yī)學(xué)院
【學(xué)位級別】：博士
【學(xué)位授予年份】：2014
【分類號】：R512.62;R575.2;R735.7

【共引文獻(xiàn)】

相關(guān)期刊論文 前10條

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