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磁共振质子密度脂肪分数（MRI-PDFF）评估慢性HBV感染者肝脂肪变性及分布特点
DOI: 10.12449/JCH240511
伦理学声明： 本研究方案于2021年5月26日经由北京清华长庚医院伦理委员会审批，批号：21228-0-01，所纳入患者均签署知情同意书。
利益冲突声明：本文不存在任何利益冲突。
作者贡献声明：王丽旻负责课题设计，资料分析，撰写论文；包超、赵凯越、靳婕华参与收集数据；黄缘、郑卓肇负责拟定写作思路，指导撰写文章并最后定稿。
Value of magnetic resonance imaging-proton density fat fraction in evaluating the degree and distribution characteristics of hepatic steatosis in patients with chronic hepatitis B virus infection
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摘要:
目的 利用磁共振质子密度脂肪分数（MRI-PDFF）评估慢性HBV感染者的肝脂肪变性的程度。 方法 选择北京清华长庚医院2018年1月—2022年12月门诊或者住院，明确诊断为慢性HBV感染，年龄>16岁的患者。所有患者均在本院行肝脏磁共振检查。依据是否合并肝硬化进行分组，比较患者的各个肝段PDFF值的一致性。使用Kappa一致性检验、组内相关系数（ICC）进行一致性分析。 结果 纳入76例核苷（酸）类似物经治患者，其中30.26%（23例）合并肝硬化，所有患者的MRI-PDFF算术均值波动在1.49%～30.93%，依据MRI-PDFF≥5%诊断为脂肪肝，38.16%（29例）患者合并脂肪肝。76例患者的全肝PDFF算术均值低于全肝PDFF加权均值，全肝PDFF加权均值、全肝PDFF算术均值、左半肝及右半肝的PDFF算术均值比较，差异无统计学意义（F=0.39，P=0.76）。各个肝段、左/右半肝PDFF算术均值与全肝PDFF加权均值、全肝PDFF算术均值的一致性较强（ICC均>0.75），但右半肝PDFF算术均值与全肝PDFF加权均值的一致性高于左半肝。合并肝硬化组患者在区分脂肪肝诊断的一致性检验方面，Ⅶ段PDFF算术均值与全肝PDFF加权均值一致性差（Kappa=0.39），左半肝、Ⅰ、Ⅱ、Ⅲ、Ⅴ、Ⅵ、Ⅷ为中等一致。合并肝硬化的患者Ⅶ段PDFF算术均值与全肝PDFF加权均值一致性最低，Ⅳ段一致性最高。未合并肝硬化的患者Ⅱ段PDFF算术均值与全肝PDFF加权均值一致性最低，Ⅴ段的一致性最高。 结论 MRI-PDFF评估慢性HBV感染者的肝脂肪变性更全面，合并肝硬化的患者各肝段PDFF算术均值与全肝PDFF加权均值的一致性差异大。 Abstract:Objective To investigate the value of magnetic resonance imaging-proton density fat fraction （MRI-PDFF） in evaluating hepatic steatosis in patients with chronic hepatitis B virus （HBV） infection. Methods The patients， aged >16 years， who visited the outpatient service or were hospitalized in Beijing Tsinghua Changgung Hospital from January 2018 to December 2022 and were diagnosed with chronic HBV infection were enrolled， and all patients underwent MRI examination of the liver in our hospital. The patients were divided into groups based on the presence or absence of liver cirrhosis， and the consistency in PDFF between different hepatic segments was compared between groups. The Kappa consistency test and intraclass correlation coefficient （ICC） were used for consistency analysis. Results A total of 76 patients treated with nucleoside analogues were enrolled， among whom 23 （30.26%） had liver cirrhosis. For all patients， the simple arithmetic average of PDFF fluctuated between 1.49% and 30.93%. According to MRI-PDFF ≥5% as the diagnostic criterion for fatty liver disease， there were 29 patients （38.16%） with fatty liver disease among all patients. For all 76 patients， the simple arithmetic average of PDFF was lower than the weighted average of PDFF for the whole liver， and there was no significant difference between the simple arithmetic average of PDFF， the weighted average of PDFF， and the PDFF values of the left and right lobes of the liver （F=0.39， P=0.76）. The consistency test showed that the PDFF values of each hepatic segment and the left and right lobes of the liver had strong consistency with the weighted average and simple arithmetic average of PDFF， with an ICC of >0.75， but the consistency between the PDFF value of the right lobe and the weighted average of PDFF was higher than that between the PDFF value of the left lobe and the weighted average of PDFF. In the consistency test of differentiating fatty liver disease in patients with liver cirrhosis， there was poor consistency between the PDFF value of segment Ⅶ and the weighted average of PDFF （Kappa=0.39）， with moderate consistency for the left lobe and the Ⅰ， Ⅱ， Ⅲ， Ⅴ， Ⅵ， and Ⅷ segments. For the patients with liver cirrhosis， the lowest consistency was observed between the PDFF value of Ⅶ segment and the weighted average of PDFF for the whole liver， and the highest consistency was observed between the PDFF value of Ⅵ segment and the weighted average of PDFF for the whole liver. For the patients without liver cirrhosis， the lowest consistency was observed between the PDFF value of Ⅱ segment and the weighted average of PDFF for the whole liver， and the highest consistency was observed between the PDFF value of Ⅴ segment and the weighted average of PDFF for the whole liver. Conclusion MRI-PDFF is more comprehensive in evaluating hepatic steatosis in patients with chronic HBV infection， and for the patients with liver cirrhosis， there is poor consistency between the PDFF value of each segment and the weighted average of PDFF. -
Key words:
- Hepatitis B virus /
- Fatty Liver /
- Magnetic Resonance Imaging
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【据Hepatology international 2021年1月报道】题：低剂量利福昔明可预防肝硬化失代偿期患者的并发症并提高生存率(作者Zeng X等)
利福昔明已被推荐作为肝性脑病(HE)和自发性细菌性腹膜炎(SBP)的预防药物。该研究旨在探讨低剂量利福昔明是否能预防肝硬化患者的整体并发症和延长生存期。
在这项多中心随机开放标签的前瞻性研究中，200例失代偿期肝硬化患者按1∶1的比例随机分配。利福昔明组患者给予利福昔明400 mg，每日2次，疗程6个月，其余治疗策略在两组患者中尽量保持不变。主要疗效终点是总并发症发生率和无肝移植生存率。次要终点是各种主要肝硬化相关并发症的发生率，以及Child-Pugh评分和分级。
除HE外，两组主要的基线特征相似。利福昔明组总并发症的累积发生率明显低于对照组(P＜0.001)。虽然两组间无肝移植生存率无显著差异，但亚组分析显示，利福昔明显著延长Child-Pugh评分≥9的患者无肝移植生存率(P=0.007)。此外，利福昔明显著减少腹水加重(P＜0.001)、HE (P＜0.001)和胃静脉曲张出血(P=0.031)的发生。两组不良事件发生率相似。
在该研究中，低剂量利福昔明显著降低了总体并发症的发生，延长了晚期肝硬化患者的生存期。低剂量利福昔明与正常剂量(1200 mg/d)利福昔明在预防肝硬化相关并发症方面的效果有待进一步研究。
摘译自ZENG X, SHENG X, WANG PQ, et al. Low-dose rifaximin prevents complications and improves survival in patients with decompensated liver cirrhosis[J]. Hepatol Int, 2021, 15(1): 155-165.
(吉林大学第一医院感染病中心肝病科 朱玉凡 牛俊奇 报道)
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表 1 患者的临床特征
Table 1. Clinical characteristics of patients
项目 数值 性别［例（%）］ 男 53（69.74） 女 23（30.26） 年龄（岁） 42（36～54） BMI（kg/m2） 24.95±3.89 合并肝硬化［例（%）］ 23（30.26） 受控衰减参数（dB/m） 262.36±36.72 MRI-PDFF（%） 6.89±5.32 LSM（kPa） 8.96±4.14 HBeAg阳性［例（%）］ 28（36.84） HBV DNA阳性［例（%）］ 16（21.05） ALT（U/L） 40.34±28.10 AST（U/L） 30.00±11.20 TBil（mmol/L） 15.11±11.50 Alb（g/L） 47.77±26.40 PLT（×109/L） 211.86±77.61 TC（mmol/L） 4.63±2.11 TG（mmol/L） 1.71±0.82 LDL-C（mmol/L） 2.77±0.91 
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表 2 76例患者肝脏各部位的PDFF值
Table 2. PDFF of liver segments in 76 patients
项目 均值（%） 标准差（%） 最小值（%） 最大值（%） P25（%） P50（%） P75（%） 全肝加权 6.91 5.97 1.14 30.89 2.36 3.35 7.96 全肝 6.89 5.32 1.49 30.93 2.35 3.36 8.08 左半肝 6.29 5.53 0.81 30.71 1.93 3.11 8.27 右半肝 7.27 5.93 1.31 30.98 2.36 3.50 8.36 Ⅰ段 6.45 4.53 0.88 24.31 2.00 4.00 8.55 Ⅱ段 7.03 6.37 0.32 32.80 2.41 4.44 8.58 Ⅲ段 6.19 5.68 0.20 34.10 1.52 2.63 9.30 Ⅳ段 6.86 5.41 0.67 32.74 2.73 3.35 8.01 Ⅴ段 7.14 6.06 0.72 33.22 2.33 3.16 8.71 Ⅵ段 7.16 6.47 0.93 28.80 2.83 3.17 8.22 Ⅶ段 7.17 6.43 1.01 31.12 2.17 3.74 10.14 Ⅷ段 7.49 6.63 0.83 33.54 2.46 4.16 11.51 注：P25，第25百分位数，P50，中位数，P75，第75百分位数。
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表 3 各肝段、左/右半肝PDFF算术均值与全肝PDFF加权均值、全肝PDFF算术均值的一致性
Table 3. Consistency of arithmetic mean PDFF of each hepatic segment and left/right lobes of the liver with weighted mean PDFF of the whole liver and arithmetic mean PDFF of the whole liver
项目 全肝加权均值 全肝算术均值 ICC值 P值 ICC值 P值 全肝加权均值 - 0.96 <0.01 全肝算术均值 0.96 <0.01 - 左半肝算术均值 0.97 <0.01 0.92 <0.01 右半肝算术均值 0.99 <0.01 0.98 <0.01 Ⅰ段算术均值 0.96 <0.01 0.92 <0.01 Ⅱ段算术均值 0.92 <0.01 0.97 <0.01 Ⅲ段算术均值 0.95 <0.01 0.91 <0.01 Ⅳ段算术均值 0.98 <0.01 0.98 <0.01 Ⅴ段算术均值 0.99 <0.01 0.99 <0.01 Ⅵ段算术均值 0.96 <0.01 0.97 <0.01 Ⅶ段算术均值 0.98 <0.01 0.98 <0.01 Ⅷ段算术均值 0.97 <0.01 0.96 <0.01
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表 4 各肝段及全肝PDFF算术均值和全肝PDFF加权均值对肝脂肪变性诊断的一致性比较
Table 4. Comparison of the consistency of arithmetic mean PDFF of each hepatic segment and the whole liver and weighted mean PDFF of the whole liver in diagnosis of hepatic steatosis
项目 区分PDFF≥5%和<5%的Kappa值 P值 全肝 0.97 <0.01 左半肝 0.86 <0.01 右半肝 0.94 <0.01 Ⅰ段 0.89 <0.01 Ⅱ段 0.86 <0.01 Ⅲ段 0.88 <0.01 Ⅳ段 0.91 <0.01 Ⅴ段 0.91 <0.01 Ⅵ段 0.86 <0.01 Ⅶ段 0.88 <0.01 Ⅷ段 0.86 <0.01
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表 5 合并肝硬化与未合并肝硬化全肝加权PDFF均值与各个肝段PDFF算术均值的一致性比较
Table 5. Comparison of the consistency of weighted mean PDFF of the whole liver and arithmetic mean PDFF of each hepatic segment in patients with and without liver cirrhosis
项目 合并肝硬化（n=23） 未合并肝硬化（n=53） ICC值 P值 Kappa值 P值 ICC值 P值 Kappa值 P值 左半肝 0.81 <0.01 0.56 <0.01 0.96 <0.01 0.87 <0.01 右半肝 0.88 <0.01 0.83 <0.01 0.99 <0.01 0.92 <0.01 Ⅰ段 0.78 <0.01 0.57 <0.01 0.97 <0.01 0.83 <0.01 Ⅱ段 0.76 <0.01 0.48 0.02 0.95 <0.01 0.75 <0.01 Ⅲ段 0.82 <0.01 0.65 <0.01 0.95 <0.01 0.79 <0.01 Ⅳ段 0.87 <0.01 0.83 <0.01 0.99 <0.01 0.87 <0.01 Ⅴ段 0.82 <0.01 0.65 <0.01 0.99 <0.01 0.92 <0.01 Ⅵ段 0.74 <0.01 0.48 <0.01 0.99 <0.01 0.83 <0.01 Ⅶ段 0.68 <0.01 0.39 0.03 0.99 <0.01 0.84 <0.01 Ⅷ段 0.76 <0.01 0.57 <0.01 0.98 <0.01 0.82 <0.01 注：ICC值，全肝PDFF加权均值与左半肝、右半肝、各个肝段PDFF算术均值的相关系数；Kappa值，区分PDFF≥5%和<5%的Kappa值。
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