原发性胆汁性胆管炎合并代谢相关脂肪性肝病的临床特征及危险因素分析
DOI: 10.12449/JCH240815
Primary biliary cholangitis with metabolic associated fatty liver disease: Clinical features and risk factors
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摘要:
目的 分析原发性胆汁性胆管炎(PBC)合并代谢相关脂肪性肝病(MAFLD)的临床特征及危险因素,探讨两种疾病合并时的相互影响。 方法 选取2019年1月—2022年12月于昆明医科大学第一附属医院确诊为PBC和MAFLD的患者187例,分为PBC组70例,PBC合并MAFLD组38例,MAFLD组79例。收集病例的一般资料、临床症状、血清学指标、瞬时弹性纤维成像(FibroScan)及非侵入性纤维化指标,分析比较三组间的不同特点。计量资料三组间比较采用单因素方差分析或Kruskal-Wallis H检验;计数资料组间比较使用χ2检验或Fisher精确检验。多因素分析采用二元Logistic回归分析。 结果 三组在性别、年龄、身高、体质量、BMI、自身免疫性疾病病史方面差异均有统计学意义(P值均<0.05)。PBC合并MAFLD组以女性患者多见(89.5%),平均年龄为(57.26±12.72)岁,BMI为(23.35±3.70) kg/m2;PBC组中自身免疫性疾病病史检出率为25.7%(18例)。三组乏力、纳差、瘙痒、黄疸、静脉曲张、腹水、脾大发生率比较,差异均有统计学意义(P值均<0.05)。PBC合并MAFLD组患者常见的症状为乏力、纳差、腹痛、腹胀,分别为18例(47.4%)、15例(39.5%)、14例(36.8%)、16例(42.1%);MAFLD组患者常见的症状为腹痛、腹胀,分别为34例(43%)、32例(40.5%);PBC组患者常见的症状及并发症为乏力、纳差、黄疸、腹痛、腹胀、静脉曲张、腹水、脾大,分别为37例(52.9%)、25例(35.7%)、25例(35.7%)、18例(25.7%)、25例(35.7%)、19例(27.9%)、23例(32.9%)、44例(62.9%)。PBC合并MAFLD组的CAP值高于PBC组(P<0.05);PBC组的LSM值、APRI、FIB-4均高于MAFLD组(P值均<0.05)。将不存在多重共线性的因素纳入回归分析,以PBC组为参照组,FIB-4(OR=0.218,95%CI:0.069~0.633)、自身免疫性疾病病史(OR=0.229,95%CI:0.067~0.810)为PBC合并MAFLD的独立影响因素(P值均<0.05);以MAFLD组为参照组,ALT(OR=0.157,95%CI:0.025~1.000)、TBil(OR=0.995,95%CI:0.990~0.999)为PBC合并MAFLD的独立影响因素(P值均<0.05)。 结论 PBC合并MAFLD临床表现并不特异,但PBC患者的临床表现更为严重,且肝功能失代偿发生率更高。两种疾病合并不一定会加重PBC的疾病进展。 Abstract:Objective To investigate the clinical features and risk factors of primary biliary cholangitis (PBC) comorbid with metabolic associated fatty liver disease (MAFLD) and the interaction between the two diseases. Methods A total of 187 patients who were diagnosed with PBC, MAFLD, or PBC with MAFLD in The First Affiliated Hospital of Kunming Medical University from January 2019 to December 2022 were enrolled and divided into PBC group with 70 patients, PBC+MAFLD group with 38 patients, and MAFLD group with 79 patients. Related data were collected, including general information, clinical symptoms, serological parameters, transient elastography (FibroScan), and non-invasive fibrosis markers, which were compared between the three groups. A one-way analysis of variance or the Kruskal-Wallis H test was used for comparison of continuous data between groups, the chi-square test or the Fisher’s exact test was used for comparison of categorical data between groups, and the binary Logistic regression analysis was used for multivariate analysis. Results There were significant differences between the three groups in sex, age, height, weight, body mass index (BMI), and history of autoimmune diseases (P<0.05). In the PBC+MAFLD group, female patients accounted for 89.5%, with a mean age of 57.26±12.72 years and a BMI of 23.35±3.70 kg/m2, and in the PBC group, the detection rate of autoimmune diseases was 25.7% (18 patients). There were significant differences between the three groups in the incidence rates of weakness, poor appetite, pruritus, jaundice, varices, ascites, and splenomegaly (all P<0.05). The PBC+MAFLD group had the common symptoms of weakness in 18 patients (47.4%), poor appetite in 15 patients (39.5%), abdominal pain in 14 patients (36.8%), and abdominal distension in 16 patients (42.1%); the MAFLD group had the common symptoms of abdominal pain in 34 patients (43%) and abdominal distension in 32 patients (40.5%); the PBC group had the common symptoms of weakness in 37 patients (52.9%), poor appetite in 25 patients (35.7%), jaundice in 25 patients (35.7%), abdominal pain in 18 patients (25.7%), abdominal distension in 25 patients (35.7%), varices in 19 patients (27.9%), ascites in 23 patients (32.9%), and splenomegaly in 44 patients (62.9%). The PBC+MAFLD group had a controlled attenuation parameter (CAP), which was higher than that of the PBC group, and the PBC group had significantly higher levels of liver stiffness measurement, aspartate aminotransferase-to-platelet ratio index (APRI), and fibrosis-4 (FIB-4) than the MAFLD group (all P<0.05). The factors without multicollinearity were included in the regression analysis, and with the PBC group as the reference group, FIB-4 (odds ratio [OR]=0.218, 95% confidence interval [CI]: 0.069 — 0.633, P<0.05) and history of autoimmune diseases (OR=0.229, 95%CI: 0.067 — 0.810, P<0.05) were influencing factors for the onset of PBC with MAFLD; with the MAFLD group as the reference group, ALT (OR=0.157, 95%CI: 0.025 — 1.000, P<0.05) and TBil (OR=0.995, 95%CI: 0.990 — 0.999, P<0.05) were influencing factors for the onset of PBC with MAFLD. Conclusion PBC with MAFLD lacks specific clinical manifestations, and PBC patients tend to have more severe clinical manifestations and a higher incidence rate of liver function decompensation. PBC comorbid with MAFLD may not aggravate the disease progression of PBC. -
表 1 MAFLD组、PBC合并MAFLD组与PBC组一般资料的比较
Table 1. Comparisons of clinical information among MAFLD group and MAFLD combined with PBC group and MAFLD group
项目 MAFLD组(n=79) PBC合并MAFLD组(n=38) PBC组(n=70) 统计值 P值 性别[例(%)] χ2=39.297 <0.001 男 42(53.2) 4(10.5) 8(11.4) 女 37(46.8) 34(89.5) 62(88.6) 民族[例(%)] χ2=2.313 0.339 汉族 72(91.1) 37(97.4) 67(95.7) 其他 7(8.9) 1(2.6) 3(4.3) 年龄(岁) 50.92±18.26 57.26±12.72 56.90±11.24 F=3.874 0.023 身高(m) 1.66±0.81 1.60±0.63 1.57±0.07 F=24.106 <0.001 体质量(kg) 68.48±12.22 59.83±12.31 53.61±9.23 F=32.995 <0.001 BMI(kg/m2) 24.87±3.56 23.35±3.70 21.58±3.11 F=17.006 <0.001 高血压[例(%)] 34(43.0) 16(42.1) 23(32.9) χ2=1.805 0.406 糖尿病[例(%)] 11(13.9) 7(18.4) 5(7.1) χ2=3.239 0.198 自身免疫性疾病[例(%)] 3(3.8) 4(10.5) 18(25.7) χ2=15.726 <0.001 吸烟史[例(%)] 12(15.2) 2(5.3) 5(7.1) χ2=3.886 0.143 表 2 三组患者临床特征比较
Table 2. Distribution of clinical manifestations in MAFLD group and MAFLD combined with PBC group and MAFLD group
临床表现 MAFLD组(n=79) PBC合并MAFLD组(n=38) PBC组(n=70) χ2值 P值 乏力[例(%)] 7(8.9) 18(47.4) 37(52.9) 36.763 <0.001 纳差[例(%)] 8(10.1) 15(39.5) 25(35.7) 17.500 <0.001 瘙痒[例(%)] 0(0.0) 2(5.3) 12(17.1) 16.088 <0.001 黄疸[例(%)] 0(0.0) 3(7.9) 25(35.7) 39.060 <0.001 腹痛[例(%)] 34(43.0) 14(36.8) 18(25.7) 4.927 0.085 腹胀[例(%)] 32(40.5) 16(42.1) 25(35.7) 0.547 0.761 静脉曲张[例(%)] 0(0.0) 6(15.8) 19(27.9) 23.850 <0.001 腹水[例(%)] 0(0.0) 5(13.2) 23(32.9) 31.596 <0.001 脾大[例(%)] 0(0.0) 8(21.1) 44(62.9) 74.130 <0.001 表 3 MAFLD组、PBC合并MAFLD组与PBC组血清学及体液免疫指标的比较
Table 3. Distribution of biochemical indices in MAFLD group and MAFLD combined with PBC group and MAFLD group
指标 MAFLD组(n=79) PBC合并MAFLD组(n=38) PBC组(n=70) 统计值 P值 WBC(×109/L) 6.07±1.49 5.21±1.791) 4.79±1.621) F=12.355 <0.001 RBC(×1012/L) 4.92±0.63 4.37±0.611)2) 3.97±0.741) F=36.845 <0.001 HGB(g/L) 149.80±20.20 133.26±17.951)2) 120.79±20.891) F=39.220 <0.001 PLT(×109/L) 238.00(206.00~284.00) 186.50(152.75~246.25)1) 148.00(102.50~217.75)1) χ2=38.405 <0.001 INR 0.97(0.93~1.02) 1.01(0.96~1.60) 1.00(0.93~1.08) χ2=5.701 0.058 TP(g/L) 74.11±6.08 74.01±14.241)2) 71.92±8.781) F=713.086 <0.001 Alb(g/L) 44.43±3.89 41.96±5.862) 36.37±7.081) F=5.754 0.004 AST(U/L) 22.50(19.00~29.40) 30.45(21.45~54.67) 57.50(33.35~88.70)1) χ2=18.684 <0.001 ALT(U/L) 27.50(17.90~48.20) 29.70(21.60~48.50)1)2) 37.75(23.50~73.95)1) χ2=29.228 <0.001 TBil(μmol/L) 10.90(9.10~14.90) 13.40(10.25~16.15)1)2) 21.15(10.57~43.27) χ2=30.580 <0.001 DBil(μmol/L) 4.50(3.60~6.40) 6.05(4.20~7.62)1) 13.20(6.10~36.80)1) χ2=14.147 <0.001 IBil(μmol/L) 6.40(5.00~9.10) 6.90(5.57~9.25)1)2) 5.55(4.10~9.65)1) χ2=48.398 <0.001 TBA(μmol/L) 4.00(2.00~6.10) 12.00(4.60~26.10)1)2) 29.90(12.35~70.85)1) χ2=145.829 <0.001 ALP(U/L) 75.40(65.80~92.20) 89.20(68.92~118.15)1) 220.10(125.50~372.60)1) χ2=133.490 <0.001 CHE(KU/L) 8.97±2.08 7.48±2.261) 5.71±2.391) F=111.814 <0.001 GGT(U/L) 35.00(20.00~70.00) 73.00(36.75~171.75)1) 234.35(99.00~510.00)1) χ2=135.308 <0.001 Urea(mmol/L) 5.15±1.29 4.50±1.211) 4.92±2.061) F=501.376 <0.001 Cr(μmol/L) 78.10±17.03 72.82±16.511) 68.70±19.121) F=200.216 <0.001 UA(μmol/L) 392.58±107.38 351.49±118.631) 309.02±103.841) F=700.969 <0.001 GLU(mmol/L) 5.01±1.28 5.24±1.19 4.87±0.86 F=1.073 0.344 CHOL(mmol/L) 4.75(4.01~5.38) 5.31(3.84~5.97)1) 4.79(4.03~6.01)1) χ2=125.700 <0.001 TG(mmol/L) 1.56(1.31~2.35) 1.91(1.48~2.61)1) 1.48(1.05~2.01)1) χ2=23.096 <0.001 HDL-C(mmol/L) 1.08(0.94~1.34) 1.21(0.95~1.40)1) 1.29(1.06~1.71)1) χ2=104.357 <0.001 LDL-C(mmol/L) 2.83(2.34~3.56) 2.86(1.91~3.91)1) 2.74(2.13~3.61)1) χ2=133.879 <0.001 IgG(g/L) 12.00(10.37~13.62) 13.80(10.12~17.65)1) 15.00(12.77~18.72)1) χ2=130.111 <0.001 IgA(g/L) 2.20(1.75~2.89) 2.35(1.61~3.38) 2.72(1.93~3.69) χ2=3.421 0.181 IgM(g/L) 0.77(0.50~1.19) 1.83(0.94~3.14) 1.99(1.49~3.45)1) χ2=11.227 0.004 C3(g/L) 1.13±0.22 1.06±0.421) 1.07±0.351) F=564.158 <0.001 C4(g/L) 0.24(0.20~0.29) 0.22(0.13~0.26) 0.18(0.13~0.24)1) F=4.262 0.016 注:与MAFLD组比较,1)P<0.05;与PBC组比较,2)P<0.05。
表 4 PBC合并MAFLD组与PBC组自身免疫性肝炎抗体谱的比较
Table 4. Comparisons of circulating immune indices in liver between MAFLD combined with PBC group and MAFLD group
抗体 PBC合并MAFLD组(n=38) PBC组(n=70) χ2值 P值 ANA阳性[例(%)] 37(97.4) 67(95.7) 0.189 0.559 AMA阳性[例(%)] 22(57.9) 51(77.1) 3.742 0.053 AMA-M2阳性[例(%)] 22(57.9) 56(80.0) 6.481 0.011 AMA-3E阳性[例(%)] 20(52.6) 56(80.0) 8.848 0.003 gp210阳性[例(%)] 15(39.5) 20(28.6) 1.336 0.248 Sp100阳性[例(%)] 2(5.3) 10(14.3) 2.030 0.154 表 5 PBC合并MAFLD组与PBC组ANA分型的比较
Table 5. Comparisons of ANA typing-indices between MAFLD combined with PBC group and MAFLD group
ANA分型 PBC合并MAFLD组(n=37) PBC组(n=67) χ2值 P值 胞浆颗粒型[例(%)] 5(13.5) 8(11.9) 0.054 >0.05 核膜型[例(%)] 10(27.0) 16(23.9) 0.126 0.723 核颗粒型[例(%)] 7(18.9) 11(16.4) 0.104 0.747 核仁型[例(%)] 2(5.4) 1(1.5) 1.303 0.288 核点型[例(%)] 5(13.5) 3(4.5) 2.741 0.129 着丝点型[例(%)] 7(18.9) 18(26.9) 0.824 0.364 线粒体型[例(%)] 20(54.1) 54(80.6) 8.182 0.004 均质型[例(%)] 1(2.7) 2(3.0) 0.007 >0.05 纺锤体型[例(%)] 0(0.0) 1(1.5) 0.558 >0.05 棒环状高尔基体型[例(%)] 1(2.7) 0(0.0) 1.828 0.356 溶酶体型[例(%)] 0(0.0) 1(1.5) 0.558 >0.05 肌动蛋白型[例(%)] 0(0.0) 2(3.0) 1.126 0.537 表 6 MAFLD组、PBC合并MAFLD组与PBC组FibroScan参数的比较
Table 6. Comparisons of FibroScan among MAFLD group and MAFLD combined with PBC group and MAFLD group
指标 MAFLD组(n=79) PBC合并MAFLD组(n=38) PBC组(n=70) 统计值 P值 CAP(db/m) 288.12±37.18 264.09±62.172) 195.53±31.591) F=39.642 <0.001 LSM(kPa) 5.30(3.70~7.40) 8.00(5.10~19.70)1) 12.00(8.05~30.30)1) χ2=27.916 <0.001 APRI 0.28(0.23~0.40) 0.44(0.27~0.93)1)2) 1.34(0.50~2.11)1) χ2=58.665 <0.001 FIB-4 0.56(0.40~0.60) 1.57(1.04~2.78)1)2) 3.66(3.57~5.65)1) χ2=66.028 <0.001 注:与MAFLD组比较,1)P<0.05;与PBC组比较,2)P<0.05。
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