中文English
ISSN 1001-5256 (Print)
ISSN 2097-3497 (Online)
CN 22-1108/R

Value of a risk assessment model in predicting venous thromboembolism in patients with liver failure after artificial liver support therapy

DOI: 10.3969/j.issn.1001-5256.2023.03.019
Research funding:

Research funding: National Natural Science Foundation of China (81702011);

Research Project of Modern Hospital Management and Development Institute of Nanjing University and Medical Development and Medical Assistance Fund of Nanjing Drum Tower Hospital (NDYG2021016)

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  • Corresponding author: LU Sufang, sufanglu0708@126.com (ORCID: 0000-0001-5471-2511)
  • Received Date: 2022-08-01
  • Accepted Date: 2022-10-11
  • Published Date: 2023-03-20
  •   Objective  To investigate the value of a risk assessment model in predicting venous thromboembolism (VTE) in patients with liver failure after artificial liver support therapy.   Methods  A retrospective analysis was performed for the clinical data of 124 patients with liver failure who received artificial liver support therapy in Affiliated Drum Tower Hospital of Nanjing University Medical School from March 2019 to December 2021, among whom there were 41 patients with VTE (observation group) and 143 patients without VTE (control group). Related clinical data were compared between the two groups, and the Caprini risk assessment model was used for scoring and risk classification of the patients in both groups. The t-test was used for comparison of continuous data between two groups; the chi-square test was used for comparison of categorical data between two groups; the Mann-Whitney U rank sum test was used for comparison of ranked data between two groups. The logistic regression analysis was used to investigate the independent risk factors for VTE in patients with liver failure after artificial liver support therapy. The receiver operating characteristic (ROC) curve was used to investigate the value of Caprini score and the multivariate predictive model used alone or in combination in predicting VTE.  Results  The observation group had a significantly higher Caprini score than the control group (4.39±1.10 vs 3.12±1.04, t=6.805, P < 0.001). There was a significant difference between the two groups in risk classification based on Caprini scale (P < 0.05), and the patients with high risk or extremely high risk accounted for a higher proportion among the patients with VTE. The univariate analysis showed that there were significant differences between the two groups in age (t=6.400, P < 0.001), catheterization method (χ2=14.413, P < 0.001), number of times of artificial liver support therapy (Z=-4.720, P < 0.001), activity (Z=-6.282, P < 0.001), infection (χ2=33.071, P < 0.001), D-dimer (t=8.746, P < 0.001), 28-day mortality rate (χ2=5.524, P=0.022). The multivariate analysis showed that number of times of artificial liver support therapy (X1) (odds ratio [OR]=0.251, 95% confidence interval [CI]: 0.111-0.566, P=0.001), activity (X2) (OR=0.122, 95%CI: 0.056-0.264, P < 0.001), D-dimer (X3) (OR=2.921, 95%CI: 1.114-7.662, P=0.029) were independent risk factors for VTE in patients with liver failure after artificial liver support therapy. The equation for individual predicted probability was P=1/[1+e-(7.425-1.384X1-2.103X2+1.072X3)]. The ROC curve analysis showed that Caprini score had an area under the ROC curve of 0.802 (95%CI: 0.721-0.882, P < 0.001), and the multivariate model had an area under the ROC curve of 0.768 (95%CI: 0.685-0.851, P < 0.001), while the combination of Caprini score and the multivariate model had an area under the ROC curve of 0.957 (95%CI: 0.930-0.984, P < 0.001).  Conclusion  The Caprini risk assessment model has a high predictive efficiency for the risk of VTE in patients with liver failure after artificial liver support therapy, and its combination with the multivariate predictive model can significantly improve the prediction of VTE.

     

  • 根据世界卫生组织最新全球调查研究1,2020年全球5岁以下儿童HBsAg感染率为0.94%,每年新增HBV感染人口150万,每年死于乙型肝炎及其并发症约82万。2016年,世界卫生组织制定了全球性战略目标,旨在2030年之前消除病毒性肝炎这一全球性公共卫生威胁,将新发感染人数降低90%,死亡率降低65%2。中国感染HBV的患者高达7 000万,这给中国完成2030年消除乙型肝炎的任务带来了严峻挑战。中国的HBV感染主要通过母婴传播途径,往往伴随着一个持续时间较长的免疫耐受期,表现以ALT水平持续正常为特征3。多项回顾性研究及荟萃分析4结果表明,ALT水平持续正常患者的肝组织并不总是完全“正常”的,有40.0%~70.0%的肝组织已经出现显著的炎症坏死(G≥2)或纤维化(S≥2),部分甚至隐匿发展为肝硬化、肝细胞癌。

    血清HBV DNA定量是评估HBV复制强度最主要的指标,用于评估疾病病程、确定抗病毒时机、判断疗效及预后等多种用途。1996年德国科学家Köck5在人体外周血清中发现HBV RNA。HBV RNA的本质是肝细胞核内闭合环状DNA(cccDNA)未经逆转录的前基因组RNA(pgRNA),未能有效地转录成松弛环状DNA(rcDNA),而是以病毒样颗粒的形式释放进入血液循环,最终形成“HBV RNA病毒样颗粒”6-9。不同于HBsAg水平受cccDNA的转录和翻译及宿主基因的HBV DNA转录的影响10,HBV RNA是cccDNA模板的直接下游产物,能更准确地反映核cccDNA库,尤其在已使用抗病毒治疗的患者中。对已使用抗病毒治疗的人群有研究11显示血清HBV RNA与肝组织病变程度及疾病进展均有关,而与未经治疗患者无关12。本研究旨在对不同正常水平ALT的CHB患者的肝组织病理与血清学指标相关性进行分析,为指导抗病毒药物使用的启动时机提供进一步依据。

    收集2018年4月—2021年6月就诊于无锡市第五人民医院ALT水平正常的CHB患者的临床资料。所有血清学标本均收集于肝活检前。筛选标准:HBsAg阳性、HBV DNA阳性,血清AST、ALT水平持续正常(1年内持续随访3次,每次至少间隔3个月)。排除标准:既往抗HBV治疗史;合并其他病毒性肝炎、酒精性肝炎、非酒精性脂肪性肝炎、自身免疫性肝病、结缔组织病、药物性肝损伤、遗传代谢性疾病、累及全身系统性疾病等;明确肝硬化患者;妊娠患者;合并有血液系统疾病、恶性肿瘤等;合并HIV感染者。

    由上海仁度生物科技股份有限公司提供血清HBV-pgRNA定量检测。使用HBV RNA实时荧光核酸恒温扩增法(simultaneous amplification and testing,SAT)试剂盒HBV-SAT kit(Shanghai Rendu Biotechnology Co.,Ltd,China)在AutoSAT全自动核酸检测分析系统上进行检测。具体操作按照AutoSAT仪器和试剂说明书进行。检测范围102~108拷贝/mL,检测下限为50拷贝/mL。

    所有患者进行肝穿刺活检前完善血常规、凝血功能、腹部超声等常规检查,排除穿刺禁忌证,签署肝穿刺活检知情同意书。患者去枕平卧位,手上抬平放至头部上方,B超引导下进行肝穿刺部位定位,对穿刺部位进行消毒,操作者戴无菌手套,铺巾,局部浸润麻醉,嘱患者配合呼吸,在B超引导下使用一次性全自动肝活体组织检查获得肝组织2条,置于4%甲醛溶液中进行组织固定,后续进行脱水、石蜡包埋、切片。肝组织分别予以HE染色、网状纤维染色、Masson染色、免疫组化染色(HBsAg和HBcAg)。

    采用我国新修订的慢性肝炎的病理学诊断标准13。将肝脏炎症活动程度≥G2定义为显著性炎症,纤维化程度≥S2定义为显著性纤维化。收集肝组织内HBsAg、HBcAg的免疫组化结果、肝脏炎症活动程度、肝纤维化分期及有无合并肝脂肪变性。

    采用SPSS 26.0软件进行统计学分析,计数资料组间比较采用χ2检验。采用Speraman秩相关进行相关性分析。采用Logistic回归进行多因素分析。P<0.05为差异有统计学意义。

    本研究共纳入137例CHB患者。其中男71例(51.8%),女66例(48.2%)。ALT≤20 U/L 47例,20~29 U/L 58例,30~40 U/L 32例。处于免疫耐受期6例(4.4%),处于免疫清除期0例,处于免疫控制期25例(18.2%),处于再活动期2例(1.5%),处于不确定期104例(75.9%)。

    CHB患者肝穿刺结果见表1。炎症活动程度分级以G2级(n=69,50.4%)为主,≥G2级82例(59.9%);肝纤维化分期以S0~1期(n=47,34.3%)、S2期(n=47,34.3%)为主,≥S2期90例(65.7%)。ALT≤20 U/L、20~29 U/L、30~40 U/L组分别有57.4%、53.4%、75%的患者发生显著炎症坏死(≥G2),63.8%、62.1%、75%发生显著纤维化(≥S2)。

    表  1  肝组织病理学炎症活动程度分级、纤维化分期情况
    Table  1.  The result of liver Liver histopathology inflammation grading, fibrosis staging
    炎症活动程度分级 例(%) 纤维化分期 例(%)
    G0~1 55(40.1) S0~1 47(34.3)
    G2 69(50.4) S2 47(34.3)
    G3 13(9.5) S3 22(16.1)
    G4 0(0.0) S4 21(15.3)
    下载: 导出CSV 
    | 显示表格

    HBeAg阳性患者的炎症活动程度分级、肝纤维化分期与HBeAg阴性患者之间差异均有统计学意义(P值均<0.05);不同水平的血清HBV DNA组间炎症活动程度分级差异有统计学意义(P<0.05),而纤维化程度差异无统计学意义(P=0.05);不同水平的血清HBV RNA组间炎症活动程度分级、纤维化分期差异均有统计学意义(P值均<0.05)。不同年龄、不同ALT水平的炎症活动程度分级及纤维化分期差异均无统计学意义(P值均>0.05)(表2)。

    表  2  临床资料与炎症活动程度分级、纤维化分期的关系
    Table  2.  Relationship of clinical data to inflammation grading and fibrosis staging
    因素 例数 炎症活动程度分级 χ2 P 肝纤维化分期 χ2 P
    G0~G1 G2 G3~G4 S0~S1 S2 S3~4
    年龄 1.814 0.404 0.711 0.701
    <30岁 8 4 4 0 2 4 2
    30~39岁 38 17 19 2 13 17 8
    ≥40岁 91 34 46 11 32 26 33
    ALT 4.858 0.088 4.755 0.093
    <20 U/L 47 20 23 4 17 22 8
    20~29 U/L 58 27 27 4 22 16 20
    30~40 U/L 32 8 19 5 8 9 15
    血清HBeAg 10.008 0.040 7.996 0.046
    阳性 28 8 12 8 10 6 12
    阴性 109 47 57 5 37 41 31
    血清HBV DNA 6.911 0.032 5.910 0.050
    <104 IU/mL 96 44 44 8 37 32 27
    104~<107 IU/mL 22 3 16 3 2 17 3
    ≥107 IU/mL 19 8 9 2 8 6 5
    血清HBV RNA 7.946 0.019 10.874 0.012
    <104拷贝/mL 96 45 45 6 39 34 23
    ≥104拷贝/mL 41 10 24 7 8 13 20
    下载: 导出CSV 
    | 显示表格

    CHB患者的炎症分级与肝纤维化分期之间存在相关性(rs =0.732,P<0.05)。HBeAg阳性与血清HBV DNA、血清HBV RNA均呈现出正相关性(rs =0.513,P=0.006;rs =0.800,P<0.001)。血清HBV DNA水平与炎症活动程度分级、纤维化分期之间无相关性(rs =0.024,P=0.785;rs =0.039,P=0.652)。血清HBV RNA与炎症活动程度分级、纤维化分期之间存在显著相关性(rs =0.222,P=0.009;rs =0.187,P=0.029)。血清HBV DNA与血清HBV RNA间无相关性(P=0.050)。

    将ALT、HBeAg、HBV DNA、HBV RNA血清学指标纳入多因素Logistic回归分析,结果提示HBeAg阳性是ALT水平正常的CHB患者肝脏发生炎症坏死(OR=-0.302,95%CI:-1.160~0.386,P=0.002)及纤维化(OR=-0.387,95%CI:-1.160~0.386,P=0.011)的独立危险因素。

    HBV感染约95%发生在婴儿期和幼儿期,相比之下仅有不到5%在成年后感染14。国内外指南将CHB感染过程分为4个阶段:HBeAg阳性慢性HBV感染(又称免疫耐受期、慢性HBV携带状态)、HBeAg阳性CHB(又称免疫清除期、免疫活动期)、HBeAg阴性慢性HBV感染(又称非活动期、免疫控制期、非活动性HBsAg携带状态)和HBeAg阴性CHB(又称再活动期)。然而临床上存在ALT水平正常、HBV DNA高水平、HBeAg阳性,看似属于HBeAg阳性的慢性HBV携带状态,即免疫耐受期,但其肝组织已出现明显炎症坏死或纤维化,根据血清HBV DNA及ALT水平难以明确感染分期,2016年和2018年美国肝病学会(AASLD)CHB指南15-16将这一情况称为不确定的“灰色地区”。2021年新加坡的一项大队列研究17对处于不确定期未经治疗的非肝硬化的CHB患者进行了平均约12.5年的长期随访,结果显示约有40%患者处于不确定期,持续处于不确定期CHB患者的肝细胞癌风险比不活跃期的CHB患者高14倍,表明不确定期的患者疾病进展风险极大,需要进一步评估抗病毒治疗的时机。中国《慢性乙型肝炎防治指南(2022年版)》18新增“不确定期”,这部分患者占CHB患者的28%~55%。而本研究纳入的137例ALT水平正常的CHB患者中,75%处于不确定期,65.7%已达到抗病毒指证,比既往研究结果高,因本研究纳入人群为ALT水平正常的CHB患者,其血清HBV DNA、肝脏病理并不完全一致,致使难以明确分期的患者比例较高。

    ALT作为肝细胞受损时最灵敏的肝酶指标,其升高通常被作为抗病毒治疗的指征之一。本研究显示ALT水平正常的CHB患者的肝组织约59.9%显著炎症坏死,65.7%显著纤维化。进一步将ALT分为不同正常水平研究,结果显示不同正常水平ALT组间炎症活动程度和纤维化程度无明显差异。纪林秀等19对ALT水平正常及轻度升高的CHB患者的肝组织活检研究显示,随着ALT水平升高,肝组织的炎症坏死及纤维化程度均加重,这与本研究结果不同,可能因为随着HBV感染的进展,ALT水平逐渐升高,病毒复制引起的免疫反应对肝细胞的损害及炎症坏死逐渐加重,而炎症坏死持续存在或反复出现是慢性HBV感染者病情进展为肝硬化甚至肝癌的重要因素。但若病毒的免疫反应仅引起炎症和纤维化,而未损伤肝细胞,此时位于肝细胞质内的酶未释放入血,血清ALT可处于正常水平。因此,血清ALT水平不能完全准确反映HBV感染者肝脏的病理改变,且其水平受到多种因素的影响。

    本研究显示ALT水平正常的CHB患者的肝脏炎症活动程度分级与纤维化分期之间存在正相关性,随着炎症程度的升高,纤维化程度越严重。ALT水平完全正常时,HBV长期感染使得肝脏反复出现炎症活动,持续不断的炎症活动持续刺激肝星状细胞活化、增殖,使得细胞外基质增生、沉积,导致肝组织内纤维化的程度逐渐升高。

    HBV复制周期中,闭合环状DNA(cccDNA)作为乙型肝炎周期的中心,血清HBV DNA定量直接反映cccDNA的水平,即HBV的复制水平20。本研究显示不同血清HBV DNA定量与炎症分级、纤维化分期之间均无相关性,这与周旋等21的研究结果一致。周保仓等22研究显示血清HBV DNA与肝脏炎症等级呈正相关,与纤维化分期无相关性。上述结果存在一定差异的原因可能是慢性HBV感染是动态活动过程,是病毒和宿主免疫系统相互作用的结果,随着感染时间的增加,病毒在体内的拷贝数呈现指数级增长,且HBV cccDNA在肝细胞核中复制转录后,病毒基因组包裹在细胞质的衣壳中,逃避宿主的免疫监视23,机体的免疫应答未能应对或出现免疫耐受,致血清HBV DNA与肝组织改变间无相关性。

    血清HBV RNA作为慢性HBV感染的新型标志物,目前研究主要集中于抗病毒治疗后的变化。本研究对未经治疗且ALT水平正常的CHB患者研究显示,血清HBV RNA与肝脏炎症程度及纤维化分期之间存在正相关性(P值均<0.05),这与Liu等24的研究一致。Bai等25研究显示pgRNA病毒粒子的包膜蛋白结构与HBV DNA病毒粒子相似,且细胞外HBV RNA具有作为合成病毒DNA模板的能力,细胞外HBV pgRNA病毒粒子可能具有感染性,使得肝组织内持续的病毒感染、复制,持续的炎症反应导致肝组织发生病变,炎症坏死及纤维化程度逐渐升高。

    本研究还发现血清HBV RNA与血清HBV DNA无相关性。这可能与HBV在肝细胞内的复制过程有关。cccDNA下游的pgRNA有两种去路,其一是被衣壳内的聚合酶通过逆转录将pgRNA转化为rcDNA,再被病毒蛋白(HBsAg脂蛋白外膜)包裹成一个新的完整的HBV释放到细胞外或进入细胞核内补充cccDNA池;其二是由HBcAg组成的核衣壳包裹,形成HBV RNA病毒颗粒并通过多种途径出胞,最终进入外周血中。同时,病毒粒子出胞途径有多种,血清HBV DNA病毒粒子是通过天然内体分选复合体(endosomal sorting complex required for transport,ESCRT)依赖性多泡体途径输出26,研究报道裸衣壳的输出是由ESCRT-0成分(肝细胞生长因子调节的酪氨酸激酶底物)和ESCRT-Ⅲ结合蛋白Alix辅助的,是完整的独立于ESCRT通路。肝细胞中是否存在裸衣壳分泌途径仍有待确定。另一方面,CHB患者血液中的一些裸衣壳可能直接来源于肝脏炎症过程中凋亡的HBV阳性细胞,而不依赖于上述途径。也有可能一些循环衣壳直接从受损的(破碎的)病毒粒子中释放27。这些不同的释放路径都会影响血清HBV RNA在外周血中的定量。

    本研究多因素Logistic回归分析显示,HBeAg阳性是CHB患者肝组织发生炎症坏死及纤维化的独立危险因素,与Bai等28研究结果一致,且随着HBeAg的升高,血清HBV DNA、HBV RNA逐渐升高。HBeAg阳性提示HBV复制活跃,传染性强,复制过程产物均升高,肝组织出现炎症及纤维化。

    总之,ALT水平正常的HBV感染者存在不同程度的显著炎症坏死及纤维化,且不同正常水平ALT的CHB患者间无明显差异,HBeAg阳性是这类患者肝组织出现显著炎症坏死及纤维化的独立危险因素。同时血清HBV RNA与肝脏炎症坏死及纤维化程度呈正相关,这使其可以作为ALT水平正常的CHB人群一个潜在的血清学指标,其临床适用性待进一步验证。对于此类患者的抗病毒治疗需结合年龄、家族史、血清HBV DNA等综合评估的基础上,提高肝穿刺活检的普及性及必要性,更及时明确抗病毒治疗的启动时机,以免延误最佳治疗时机,及时抑制病毒复制,延缓疾病发展。但本研究样本量较小,且来源于单中心,需大规模和多中心队列进一步研究未经治疗的CHB患者的血清HBV RNA,提供更多的循证医学证据。

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