本文選題：慢性HBV感染 + 非酒精性脂肪性肝病��； 參考：《天津醫(yī)科大學》2017年碩士論文

【摘要】：目的:通過觀察慢性乙型肝炎病毒(Hepatitis B Virus,HBV)感染合并非酒精性脂肪性肝病(Nonalcoholic Fatty Liver Disease,NAFLD)患者病理特征判別肝臟炎癥原因,比較它們之間的臨床特點,分析與其炎癥相關的指標,進而探討是否存在一種無創(chuàng)的方法比如公式識別這些炎癥原因,從而建立慢性HBV感染合并NAFLD炎癥無創(chuàng)臨床診斷模型。方法:收集2014年01月至2016年12月就診于天津市第二人民醫(yī)院的慢性HBV感染合并NAFLD的患者,觀察這些患者肝臟病理特征,分析炎癥引起原因,根據(jù)病理特征的不同,分為HBV炎癥組(HBV感染合并NAFLD患者有HBV感染相關炎癥活動)和非HBV炎癥組(HBV感染合并NAFLD患者無HBV感染相關炎癥活動),單因素分析比較這兩組患者一般特征和臨床資料[包括肝腎功能、血脂、血糖、尿酸、胰島素、乙肝五項、HBV-DNA、甲狀腺功能、鐵四項、免疫功能、血常規(guī)、B超、受控衰減參數(shù)(Controlled Attenuation Parameter,CAP)、FibroScan]等差異,納入具有臨床差異性的指標進行二元logistic回歸分析肝臟炎癥活動相關性指標,得出回歸公式,評價及驗證其準確性。結果:1.HBV炎癥組的病理表現(xiàn)為:匯管區(qū)擴大,單個核為主的炎細胞浸潤,或淋巴細胞集結浸潤,有界面性炎癥。非HBV炎癥組病理表現(xiàn)為:無明顯匯管區(qū)擴大及匯管區(qū)內炎細胞浸潤,無界面性炎癥。2.HBV炎癥組平均年齡(41.8±9.9歲)高于非HBV炎癥組平均年齡(36.42±10.49歲),差異有統(tǒng)計學意義(P0.05)。兩組患者性別、體重指數(shù)(Body Mass Index,BMI)均無差別(P均0.05)。HBV炎癥組炎癥較非HBV炎癥組的炎癥及纖維化程度重,但肝脂肪變程度較非HBV炎癥組輕,差異有統(tǒng)計學意義(P均0.05)。3.HBV炎癥組ALT、AST、GGT、ALP均高于非HBV炎癥組,差異有統(tǒng)計學意義(P均0.05)。HBV炎癥組TP、ALB、UA均低于非HBV炎癥組,差異有統(tǒng)計學意義(P均0.05)。兩組的TBIL、BUN、CRE、TG、CHO、HDL、LDL差異無統(tǒng)計學意義(P均0.05)。4.兩組HBsAg、HBeAg、HBe Ag陽性率、TT3、TT4、FT3、FT4、TSH、TGAB及胰島素差異均無統(tǒng)計學意義(P均0.05)。HBV炎癥組的HBV-DNA載量高于非HBV炎癥組,差異有統(tǒng)計學意義(P0.05)。5.HBV炎癥組補體C3水平低于非HBV炎癥組,差異具有統(tǒng)計學意義(P0.05);兩組補體C4、IgG、IgA、IgM、TFR、Fe、FER、TIBC、UIBC均無差別(P均0.05)。6.HBV炎癥組WBC、NEUT、PLT均低于非HBV炎癥組,差異有統(tǒng)計學意義(P均0.05),MPV、MCV均高于非活動性HBV組,差異有統(tǒng)計學意義(P均0.05)。兩組LYMPH、RBC、HGB、HCT差異均無統(tǒng)計學意義(P均0.05)。7.HBV炎癥組CAP值低于非HBV炎癥組,肝硬度值高于非HBV炎癥組,差異有統(tǒng)計學意義(P均0.05)。8.逐步logistic回歸分析后,年齡、CAP、E、ALT等四個因子差異有統(tǒng)計學意義(P均0.05),所得的回歸方程為Y=0.106×年齡-0.033×CAP+0.48×E+0.048×ALT-0.86,預測的整體正確率為83.1%。此公式相應的AUC=0.922,P0.001,cut-off值為0.534,靈敏度為80%,特異度為90.91%,陽性預測值為93.6%,陰性預測值為73.2%。9.公式Y=0.106×年齡-0.033×CAP+0.48×E+0.048×ALT-0.86在驗證組正確率為63.64%,但所有的用公式診斷為活動性HBV組的(Y0.534)與病理結果診斷一致,符合率100%。結論:1.HBV感染合并NAFLD患者有HBV感染相關炎癥活動(HBV炎癥組)的特征為:血清學HBV標記物陽性,同時肝組織免疫組化HBs Ag、HBcAg、PreS1Ag至少一項陽性;肝組織脂肪變性符合NAFLD形態(tài)學特征;肝組織匯管區(qū)擴大,單個核為主的炎細胞浸潤,或淋巴細胞集結浸潤,至少有輕度的界面性炎癥。2.HBV感染合并NAFLD患者無HBV感染相關炎癥活動(非HBV炎癥組)的特征為:血清學HBV標記物陽性,同時肝組織免疫組化HBsAg、HBcAg、PreS1Ag至少一項陽性;肝組織脂肪變性符合NAFLD形態(tài)學特征;肝臟組織匯管區(qū)擴大及匯管區(qū)內炎細胞浸潤均不明顯,無界面炎癥;除外:a.明確的中央靜脈周圍炎,伴或不伴中央靜脈周圍網狀支架塌陷b.肝竇內kuffer細胞臘樣質沉積。慢性HBV感染合并NAFLD患者的肝臟炎癥大部分是由HBV感染引起的。3.HBV炎癥組較非HBV炎癥組患者的肝臟炎癥及纖維化比較明顯。且這些患者年齡大,臨床上常常ALT、AST、GGT、ALP、HBV-DNA水平升高,且FibroScan值大,CAP值小,血常規(guī)可出現(xiàn)WBC、NEUT、PLT等下降、MPV升高,這些簡單的臨床指標為HBV感染合并NAFLD患者炎癥原因判別有一定預示意義。4.可以參考公式Y=0.106×年齡-0.033×CAP+0.48×E+0.048×ALT-0.86初篩,若Y值0.534,考慮肝臟炎癥與HBV感染炎癥有關,需高度重視HBV的問題,必要時行抗病毒治療。當然,此公式的實用性有待進一步驗證。
[Abstract]:Objective: to identify the causes of liver inflammation by observing the pathological features of patients with chronic hepatitis B virus (Hepatitis B Virus, HBV) infection combined with non-alcoholic fatty liver disease (Nonalcoholic, Liver Disease, NAFLD), compare the clinical characteristics between them, and analyze the indexes related to their inflammation, and then discuss the existence of a non-invasive prescription. Methods such as formulae identify these inflammatory causes and establish a noninvasive clinical diagnostic model for chronic HBV infection with NAFLD inflammation. Methods: to collect chronic HBV infection with NAFLD in Second People's Hospital of Tianjin from 01 months to December 2016, and observe the pathological features of these patients, analyze the causes of inflammation, and according to the pathology. The characteristics were divided into HBV inflammation group (HBV infection combined with NAFLD patients with HBV infection related inflammatory activity) and non HBV inflammation group (HBV infection with NAFLD patients without HBV infection related inflammatory activities). Single factor analysis compared the general characteristics and clinical data of these two groups [including liver and kidney function, blood lipid, blood sugar, uric acid, insulin, hepatitis B, hepatitis B, HBV, HBV, HBV, HBV, HBV -DNA, thyroid function, four iron, immune function, blood routine, B ultrasound, controlled attenuation parameters (Controlled Attenuation Parameter, CAP), FibroScan] and other differences, included in the index of clinical differential and logistic regression analysis of the correlation index of liver inflammation, regression formula, evaluation and verification of its accuracy. Results: 1.HBV The pathological features of the inflammatory group were: enlargement of sinks, infiltration of mononuclear inflammatory cells, or lymphocytic infiltration, and interfacial inflammation. The pathological manifestations of non HBV inflammatory groups were: no obvious enlargement of sinks and infiltration of inflammatory cells in the sinks, and the average age of 41.8 + 9.9 years in the group without interfacial inflammation (41.8 + 9.9 years) was higher than the average of non HBV inflammation group. Age (36.42 + 10.49 years), the difference was statistically significant (P0.05). There was no difference in sex, body mass index (Body Mass Index, BMI) in the two groups (P 0.05). The inflammation and fibrosis degree of.HBV inflammation group was more severe than that of non HBV inflammation group, but the degree of hepatic steatosis was less than that of non HBV inflammatory group, and the difference was statistically significant (P 0.05).3.HBV inflammatory group ALT. GT and ALP were higher than non HBV inflammatory groups (P 0.05).HBV inflammation group TP, ALB, UA were lower than non HBV inflammatory groups, and the difference was statistically significant (P 0.05). No statistical significance (P 0.05).HBV inflammation group was higher than non HBV inflammation group, the difference was statistically significant (P0.05).5.HBV inflammation group C3 level was lower than non HBV inflammation group, the difference was statistically significant (P0.05). In the non HBV inflammation group, the difference was statistically significant (P 0.05), MPV, MCV were higher than the non active HBV group, the difference was statistically significant (P 0.05). The difference of LYMPH, RBC, HGB, HCT was not statistically significant (P 0.05) in the two groups. After the stepwise logistic regression analysis, the four factors of age, CAP, E, ALT were statistically significant (P 0.05). The regression equation was Y=0.106 x -0.033 x CAP+0.48 x E+0.048 x ALT-0.86, the overall accuracy of the prediction was 83.1%., 0.534, the sensitivity was 80%, the specificity was 90.91%, and the positive rate was 90.91%. The predictive value was 93.6%, the negative predictive value was 73.2%.9. Y=0.106 x age -0.033 x CAP+0.48 x E+0.048 x ALT-0.86 in the verification group, the correct rate was 63.64%, but all the formula diagnosed as active HBV group (Y0.534) was consistent with the pathological diagnosis, and the coincidence rate was 100%. conclusion: 1.HBV infection combined NAFLD patients with HBV infection related inflammatory activities. The characteristics of inflammation group were: serological HBV markers positive, and liver tissue immunization of HBs Ag, HBcAg, PreS1Ag at least one positive; liver tissue fatty degeneration conformed to NAFLD morphological characteristics; liver tissue enlargement area, mononuclear mainly inflammatory cell infiltration, or lymphatic cell aggregation infiltration, at least mild interfacial inflammation.2.HBV infection NAFLD patients without HBV infection related inflammatory activities (non HBV inflammation group) were characterized by positive serological HBV markers, and at least one positive of HBsAg, HBcAg and PreS1Ag in liver tissue; fatty degeneration of liver tissue was conformed to NAFLD morphological characteristics, and the enlargement of liver tissue and the infiltration of inflammatory cells in the sinks were not obvious and no interface Inflammation; excepted: A. clear central phlebitis, with or without the collapse of the mesostatic stent around the central vein of Kuffer cell paranotic deposition in the B. hepatic sinusoid. The liver inflammation in patients with chronic HBV infection combined with NAFLD is most obvious in the.3.HBV inflammation group caused by HBV infection and in the liver inflammation and fibrosis in the patients with non HBV inflammation. Some patients are older, often ALT, AST, GGT, ALP, HBV-DNA, and FibroScan value, CAP value, WBC, NEUT, PLT and so on, and MPV increase. +0.048 x ALT-0.86 initial screening, if Y value 0.534, to consider the liver inflammation and HBV infection and inflammation, it is necessary to attach great importance to the problem of HBV, when necessary antiviral treatment. Of course, the practicality of this formula needs to be further verified.
【學位授予單位】：天津醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R512.62;R575

【參考文獻】

相關期刊論文 前10條

1 楊秀珍;耿愛文;肖麗;咸建春;;慢性乙型肝炎合并脂肪肝臨床與肝組織病理學分析[J];實用肝臟病雜志;2017年01期

2 任金晴;徐亮;張艦瓊;李萍;劉勇鋼;周小莉;宓余強;;急性病毒性肝炎患者肝功能指標與血脂的相關性研究[J];實用肝臟病雜志;2017年01期

3 張艦瓊;徐亮;李萍;劉勇鋼;石瑞芳;宓余強;;四種方法診斷慢性乙型肝炎合并輕度肝脂肪變患者肝纖維化比較[J];實用肝臟病雜志;2016年06期

4 Laurence J Britton;V Nathan Subramaniam;Darrell HG Crawford;;Iron and non-alcoholic fatty liver disease[J];World Journal of Gastroenterology;2016年36期

5 沈峰;鄭瑞丹;宓余強;施軍平;王曉穎;胡錫琪;潘勤;徐雷鳴;范建高;;細胞角蛋白-18聯(lián)合受控衰減參數(shù)二步法無創(chuàng)鑒別非酒精性脂肪性肝炎的臨床研究[J];中華肝臟病雜志;2016年06期

6 張志僑;王功遂;康凱夫;吳國標;王鵬;;基于216對配對病例研究慢性乙型肝炎患者肝脂肪變性的臨床和病理特征[J];中華傳染病雜志;2016年03期

7 王明芳;林蘇;吳銀蓮;朱月永;江家驥;;慢性乙型肝炎患者肝脂肪變性與血清、肝組織病毒因素的關系[J];中華傳染病雜志;2016年03期

8 孫靜芳;續(xù)薇;;HBV感染患者血清鐵代謝指標與肝損傷關系的探討[J];中國實驗診斷學;2016年02期

9 楊美;劉義思;周光德;郭曉東;鄒賽英;劉樹紅;蔣麗娜;劉元;朱莉;郭超楠;趙景民;;血清骨保護素對非酒精性脂肪性肝炎無創(chuàng)性診斷的價值[J];中華肝臟病雜志;2016年02期

10 ;慢性乙型肝炎防治指南(2015更新版)[J];肝臟;2015年12期

，

本文編號：1921097