慢性乙型肝炎患者骨量减少/骨质疏松的危险因素及CT值的诊断价值

张静怡; 唐映梅; 李嘉琦; 王倩; 张宸瑞

doi:10.3969/j.issn.1001-5256.2022.05.013

慢性乙型肝炎患者骨量减少/骨质疏松的危险因素及CT值的诊断价值

DOI: 10.3969/j.issn.1001-5256.2022.05.013

a.
昆明医科大学第二附属医院消化内科，昆明 650000
b.
昆明医科大学第二附属医院放射科，昆明 650000

基金项目:

国家自然科学基金 (81660102);

国家自然科学基金 (81360072)

伦理学声明：本研究方案于2020年7月15日经由昆明医科大学第二附属医院伦理委员会批准，批号：审-PJ-2020-56。所有研究对象均知情同意。

利益冲突声明：本研究不存在研究者、伦理委员会成员、受试者监护人以及与公开研究成果有关的利益冲突。

作者贡献声明：张静怡负责课题设计，资料分析，拟定写作思路，撰写论文；李嘉琦、王倩、张宸瑞参与收集及分析数据；唐映梅负责指导撰写文章，修改论文并最后定稿。

详细信息

通信作者:
唐映梅，tangyingmei_med@kmmu.edu.cn

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出版历程
- 收稿日期: 2021-09-29
- 录用日期: 2021-11-01
- 出版日期: 2022-05-20

Risk factors for osteopenia/osteoporosis and the diagnostic value of CT value in patients with chronic hepatitis B

a.
Department of Gastroenterology, The Second Affiliated Hospital of Kunming Medical University, Kunming 650000, China
b.
Department of Radiology, The Second Affiliated Hospital of Kunming Medical University, Kunming 650000, China

Research funding:

National Natural Science Foundation of China (81660102);

National Natural Science Foundation of China (81360072)

More Information

Corresponding author: TANG Yingmei, tangyingmei_med@kmmu.edu.cn(ORCID: 0000-0002-0731-4198)

摘要

摘要: 目的评价在慢性乙型肝炎患者腹部CT中通过测量胸、腰椎CT值，诊断骨量减少/骨质疏松的诊断价值。分析慢性乙型肝炎患者发生骨量减少/骨质疏松的危险因素。方法回顾性纳入2019年1月—2020年12月在昆明医科大学第二附属医院就诊的慢性乙型肝炎患者112例，所有患者均完善了腹部CT检查，部分患者完善了双能X线骨密度测定(DXA)。测量T12椎体至L3椎体的CT值，分析每一椎体CT值与DXA检查基于L1~L4椎体测得的T-score值相比诊断骨量减少/骨质疏松的诊断价值。以椎体CT值为诊断标准，将纳入的慢性乙型肝炎患者分为骨量减少/骨质疏松组(n=55)与骨量正常组(n=57)，对比两组患者临床特征、生化指标，分析慢性乙型肝炎患者发生骨量减少/骨质疏松的危险因素。符合正态分布的计量资料两组间比较采用t检验；非正态分布的计量资料两组间比较采用Mann-Whitney U检验。计数资料组间比较采用χ²检验、Fisher确切检验、Bonferroni校正检验。相关性采用Pearson相关分析。多因素分析采用二元logistic回归分析。根据受试者工作特征曲线(ROC曲线)评估T12~L3椎体CT值诊断慢性乙型肝炎患者合并骨量减少/骨质疏松的诊断价值。一致性检验采用Kappa检验。结果分析46例在同次住院中完善了腹部CT和DXA检查患者的T12~L3椎体CT值，均分别与DXA检查结果中基于L1~L4椎体计算的T-score值有显著正相关性(r_T12=0.694，r_L1=0.661，r_L2=0.781，r_L3=0.685，P值均＜0.001)；经ROC曲线分析，L2椎体CT值ROC曲线下面积最大(0.863)，诊断骨量减少/骨质疏松具有较好准确性，与DXA检查结果具有较好一致性(K=0.648，P＜0.001)。分析112例慢性乙型肝炎患者临床特征、生化指标，提示高龄(比值比为1.108，95%CI：1.026~1.196，P=0.009)、合并肌少症(比值比为2.788，95%CI：1.009~7.707，P=0.048) 是骨量减少/骨质疏松发生的危险因素。结论慢性乙型肝炎患者常需定期复查腹部CT评估肝脏疾病进展情况，通过测量患者腹部CT图像中L2椎体CT值、L3椎体层面骨骼肌面积筛查是否存在骨量减少/骨质疏松、肌少症，及时干预，提高患者的预后、生活质量，具有较高临床意义。
- 乙型肝炎, 慢性 /
- 骨质疏松 /
- 肌减少症
Abstract: Objective To investigate the value of the CT values of thoracolumbar vertebrae measured by abdominal CT in the diagnosis of osteopenia/osteoporosis in patients with chronic hepatitis B, as well as the risk factors for osteopenia/osteoporosis in such patients. Methods A retrospective analysis was performed for 112 patients with chronic hepatitis B in the Second Affiliated Hospital of Kunming Medical University from January 2019 to December 2020. All patients underwent abdominal CT, and some patients underwent dual-energy X-ray absorptiometry (DXA). The CT values of T12 vertebral body to L3 vertebral body were measured, and the value of CT value of each vertebral body in the diagnosis of osteopenia/osteoporosis was analyzed in comparison with T-score of L1-L4 vertebral bodies measured by DXA. With the CT values of vertebral bodies as the diagnostic criteria, the patients with chronic hepatitis B enrolled were divided into osteopenia/osteoporosis group with 55 patients and normal bone mass group with 57 patients. Clinical features and biochemical parameters were compared between the two groups to analyze the risk factors for osteopenia/osteoporosis in patients with chronic hepatitis B. The t-test was used for comparison of normally distributed continuous data between groups, and the Mann-Whitney U test was used for comparison of non-normally distributed continuous data between groups; the chi-square test, the Fisher's exact test, and the Bonferroni correction test were used for comparison of categorical data between groups. A Pearson correlation analysis was performed to investigate correlation, and a binary logistic regression analysis was used for multivariate analysis. The receiver operating characteristic (ROC) curve was used to investigate the value of CT values of T12-L3 vertebral bodies in the diagnosis of osteopenia/osteoporosis in patients with chronic hepatitis B. The Kappa test was used check consistency. Results A total of 46 patients who completed abdominal CT and DXA during the same time of hospitalization were analyzed, and their CT values of T12-L3 vertebral bodies were significantly positively correlated with the T-score values of L1-L4 vertebral bodies in DXA (r_T12=0.694, r_L1=0.661, r_L2=0.781, r_L3=0.685, all P < 0.001). The ROC curve analysis showed that the CT value of L2 vertebral body had the largest area under the ROC curve of 0.863 and showed a good accuracy in the diagnosis of osteopenia/osteoporosis, which was consistent with the results of DXA (K=0.648, P < 0.001). The clinical features and biochemical parameters of 112 patients with chronic hepatitis B were analyzed, and it was suggested that old age (odds ratio [OR]=1.108, 95% confidence interval [CI]: 1.026-1.196, P=0.009) and sarcopenia (OR=2.788, 95% CI: 1.009-7.707, P=0.048) were the risk factors for osteopenia/osteoporosis. Conclusion The patients with chronic hepatitis B often need regular abdominal CT to evaluate the progression of liver disease, and it is of high clinical significance to identify the presence or absence of osteopenia/osteoporosis and sarcopenia by measuring the CT value of L2 vertebral body and skeletal muscle area of L3 vertebrae plane, thereby giving timely intervention and improving patients' prognosis and quality of life.
- Hepatitis B, Chronic /
- Osteoporosis /
- Sarcopenia

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图 1 利用3区法测量椎体CT值

注：a，椎体上终板的下一层；b，椎体中间层；c，下终板的上一层。

Figure 1. Measurement of vertebral body CT values using the 3-zone method

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图 2 在同一椎体上测量每一层面HU值

注：a，椎体上终板的下一层；b，椎体中间层；c，下终板的上一层。

Figure 2. Measurement of HU values at each level on the same vertebral body

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图 3 在L3层面测量骨骼肌组织面积

Figure 3. Measurement of skeletal muscle tissue area at the L3 level

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图 4 患者T12~L3椎体CT值诊断患者骨量减少/骨质疏松的ROC曲线

Figure 4. ROC curve of patient's T12-L3 vertebral body CT values for diagnosis of patient's osteopenia/osteoporosis

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表 1 患者T12~L3椎体CT值(cut-off值)诊断患者骨量减少/骨质疏松的ROC曲线分析

Table 1. ROC curve analysis of patients' T12-L3 vertebral body CT values (cut-off values) for diagnosis of patients with osteopenia/osteoporosis

椎体位置	AUC	灵敏度	特异度	约登指数	CT值(cut-off值，HU)
T12	0.836	0.714	0.906	0.620	140.0
L1	0.828	0.786	0.781	0.567	149.5
L2	0.863	0.786	0.875	0.661	137.0
L3	0.850	0.786	0.812	0.598	135.5

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表 2 骨量减少/骨质疏松组、骨量正常组CHB患者临床特征比较

Table 2. Comparison of clinical characteristics of CHB patients in the reduced osteopenia /osteoporosis group and normal bone mass group

项目	骨量减少/骨质疏松组(n=55)	骨量正常组(n=57)	统计值	P值
年龄(岁)	57.36±5.13	53.47±6.59	t=-3.815	＜0.001
年龄≥60岁[例(%)]	17(30.9)	6(10.5)	χ²=7.126	0.008
性别[例(%)]			χ²=0.098	0.755
男	41(74.5)	41(71.9)
女	14(25.5)	16(28.1)
吸烟[例(%)]	35(63.6)	27(47.4)	χ²=2.997	0.083
饮酒[例(%)]	27(49.1)	30(35.1)	χ²=0.298	0.585
高血压[例(%)]	11(0.2)	7(12.3)	χ²=1.237	0.266
糖尿病[例(%)]	5(9.1)	12(21.1)	χ²=3.111	0.078
骨折病史[例(%)]	3(5.5)	1(1.8)	χ²=1.113	0.291
乙型肝炎病史(年)	6(1~20)	10(2~20)	Z=-0.459	0.646
抗病毒治疗[例(%)]	36(65.5)	36(63.2)	χ²=0.064	0.800
治疗疗程(月)	30(12~72)	24(4~48)	Z=-1.827	0.068
HBsAg阳性[例(%)]	54(98.2)	57(100)		0.491
HBeAg阳性[例(%)]	15(27.3)	21(36.8)	χ²=1.175	0.278
HBV DNA阳性[例(%)]	20(36.4)	28(49.1)	χ²=1.861	0.173
肝癌[例(%)]	6(10.9)	5(8.8)	χ²=0.104	0.704
肝硬化[例(%)]	47(85.5)	46(80.7)	χ²=0.449	0.503
腹水[例(%)]	30(54.5)	29(50.9)	χ²=0.151	0.697
脾大[例(%)]	41(74.5)	42(73.7)	χ²=0.011	0.917
食管胃底静脉曲张[例(%)]	42(76.4)	37(64.9)	χ²=1.766	0.184
Child-Pugh分级[例(%)]			χ²=0.408	0.815
A级	18(32.7)	19(33.3)
B级	25(45.5)	23(40.4)
C级	12(21.8)	15(26.3)
肌少症[例(%)]	19(34.5)	7(12.3)	χ²=7.784	0.005
超重[例(%)]	26(43.6)	21(29.8)	χ²=1.250	0.263
低体重[例(%)]	6(10.9)	2(3.5)	χ²=1.330	0.249

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表 3 骨量减少/骨质疏松组、骨量正常组CHB患者生化指标比较

Table 3. Comparison of biochemical indices of CHB patients in the reduced osteopenia/osteoporosis group and normal bone mass group

项目	骨量减少/骨质疏松组(n=55)	骨量正常组(n=57)	统计值	P值
ALT(U/L)	33.50(24.75~64.00)	40.00(27.00~76.00)	Z=-1.28	0.200
AST(U/L)	44.00(32.50~61.25)	45.00(33.00~96.00)	Z=-0.57	0.566
ALP(U/L)	112.50(96.75~139.00)	114.00(88.0~161.00)	Z=-0.25	0.802
GGT(U/L)	53.50(25.50~99.50)	43.00(26.00~83.00)	Z=-0.72	0.474
TBil(μmol/L)	20.10(13.48~48.75)	22.40(15.70~38.65)	Z=-0.86	0.389
白蛋白(g/L)	33.37±7.05	34.76±7.92	t=1.045	0.298
前白蛋白(μg/L)	114(81~164)	101(69~180)	Z=-0.87	0.384
eGFR(ml·min^-1·1.73 m^-2)	97.00(86.75~104.00)	101.00(89.50~105.50)	Z=-1.57	0.116
TC(mmol/L)	3.66(3.02~4.15)	3.52(2.89~4.17)	Z=-0.47	0.641
TG(mmol/L)	0.93(0.71~1.23)	0.87(0.69~1.06)	Z=-0.69	0.489
PT(s)	14.60(13.60~17.00)	15.50(14.05~17.25)	Z=-0.96	0.335
APTT(s)	38.40(34.65~42.63)	39.50(36.40~43.55)	Z=-1.03	0.302
INR	1.16(1.06~1.40)	1.25(1.11~1.43)	Z=-1.05	0.293
血小板(×10⁹/L)	95.00(58.50~151.25)	86.00(49.50~134.50)	Z=-1.19	0.233

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