晁春梅,韋嘉,楊微波
慢性乙型肝炎患者血清促肝細胞生長素的臨床意義研究
晁春梅1,韋嘉2,楊微波1
(1.昆明醫(yī)科大學第一附屬醫(yī)院感染病科;2.昆明醫(yī)科大學第四附屬醫(yī)院云南昆明650032)
目的測定慢性乙型肝炎(CHB)患者不同臨床類型組血清促肝細胞生長素(HGF)水平,分析HGF水平與臨床類型、肝功能水平、乙肝病毒血清標志物(HBVM)和HBV-DNA的關(guān)系,探討HGF在CHB的意義。方法用酶聯(lián)免疫吸附試驗(ELISA)法檢測78例CHB患者不同臨床類型組血清HGF水平,與肝功能完全正常的20例健康體檢者作對照,同時檢測肝功能、乙肝兩對半和HBV-DNA,部分病人進行了HbsAg定量測定和PT測定。結(jié)果78例CHB患者血清HGF水平為(929.10±1932.15)pg/ml;健康對照組HGF水平分別為(215.1±65.97)pg/ml,兩組HGF水平差異有統(tǒng)計學意義。78例慢性乙型肝炎患者中,抗病毒治療應(yīng)答組、HbeAg+CHB組、HbeAg-CHB組與肝衰竭組HGF水平分別為(658.20±178.20) pg/ml、(772.60±335.40)pg/ml、(958.80±1005.49)pg/ml與(5912.0±4 497.0)pg/ml,各組HGF水平均高于對照組。4個臨床類型組兩兩比較,肝衰竭組HGF水平最高,與其余各組相比,差異具有統(tǒng)計學意義;HBeAg-CHB組HGF水平>抗病毒組,差異有統(tǒng)計學意義(P<0.01);HbeAg-CHB組HGF水平>HbeAg+CHB組及HbeAg+CHB組>抗病毒組,但差異無統(tǒng)計學意義(P>0.005)。高、低病毒載量組HGF水平分別為(2 141.0±3 115.3)pg/ml與(812.50±639.80)pg/ml,差異無統(tǒng)計學意義(P>0.05)。HbsAg載量高與低組HGF水平分別為(1 258.0±2813.3)與(1794.09±5 033.0)pg/ml,差異無統(tǒng)計學意義。炎癥活動CHB組63份病例HGF與ALT、AST、Tbil相互關(guān)系經(jīng)Spearman等級相關(guān)檢驗,相關(guān)系數(shù)有統(tǒng)計學意義(P<0.05),呈正相關(guān),其中HGF與Tbil呈高度正相關(guān)。HGF與HBV-DNA相互關(guān)系經(jīng)Spearman等級相關(guān)檢驗,相關(guān)系數(shù)無統(tǒng)計學意義(P>0.05)。結(jié)論1.HGF在不同臨床類型CHB患者血清中都明顯升高,說明HGF參與了HBV感染后的免疫反應(yīng)、肝臟損傷和修復過程;2.肝衰竭組血清HGF明顯高于其余各臨床類型組,臨床使用肝細胞生長素治療肝衰竭的時機需進一步評價;3.HGF與肝損傷程度有關(guān),與HBV-DNA及HbsAg載量無明顯相關(guān)性。
乙型肝炎;血清促肝細胞生長素
乙型肝炎病毒(HBV)通過各種途徑進入機體后,可出現(xiàn)不同的感染結(jié)果,形成復雜的感染疾病譜。HBV感染的結(jié)果,很大程度上取決于感染者的年齡,此外,宿主的免疫因素也在HBV感染的過程中起到重要的作用。肝臟病變至肝細胞死亡時可有相應(yīng)的肝細胞再生,刺激肝再生的體液因子可來自肝臟和肝外組織,肝內(nèi)的有肝細胞生長因子(HGF)和胰島素樣生長因子[1]。動物實驗和人體試驗均發(fā)現(xiàn)HGF對肝損傷有保護作用[2-4],同時也是肝損傷的判斷指標之一。為進一步了解HGF在不同臨床類型慢性乙型肝炎患者中的臨床意義,我們檢測了不同臨床類型慢性乙型肝炎患者血清中的HGF含量,探討HGF在HBV慢性感染、肝衰竭中的意義,以解釋臨床現(xiàn)象,并為臨床判斷病情、預后估計和治療提供一定的理論依據(jù)。
一、研究對象
1.CHB組:根據(jù)研究目的,選擇2009年9月~2010年1月在昆明醫(yī)學院第一附屬醫(yī)院感染疾病科門診就診或住院的病人78例,按標準納入研究,其中男63例,女15例。年齡9歲~73歲,平均年齡36.0±11.8歲。按照分組標準分為,A組15例,抗病毒治療完全應(yīng)答組(簡稱抗病毒組,HBeAg陽性慢性乙型肝炎患者,治療后ALT恢復正常,HBV DNA用PCR法檢測不出,HBeAg血清學轉(zhuǎn)換;HBeAg陰性慢性乙型肝炎患者,治療后ALT恢復正常,HBV DNA用PCR法檢測不出);B組22例,HBeAg陽性慢性乙型肝炎組(簡稱HbeAg+CHB組),血清HBsAg、HBV DNA和HBeAg陽性,抗-HBe陰性,血清ALT升高>60U/L或肝組織學檢查有肝炎病變;C組22例: HBeAg陰性慢性乙型肝炎組(簡稱HBeAg﹣CHB組),HBsAg和HBV DNA陽性,HBeAg持續(xù)陰性,抗-HBe陽性或陰性,血清ALT異常>60U/L,或肝組織學檢查有肝炎病變;D組19例,肝衰竭組。診斷符合中華醫(yī)學會肝病學分會、中華醫(yī)學會感染病學分會2005年12月~2006年9月聯(lián)合制定的慢性乙型肝炎指南、肝衰竭診療指南。B組和C組年齡、肝功能損傷水平具可比性。所有病例均排外合并其他肝炎病毒感染、酒精性肝病、藥物性肝病、脂肪性肝病、自身免疫性肝病及其他急、慢性疾病。
2.健康對照組:我科門診就診體檢擬注射乙肝疫苗者20例,男14例,女6例,年齡4歲至39歲,平均年齡25.3±9.97歲(肝功能完全正常,排除甲、乙、丙、丁、戊型肝炎病毒感染,無急、慢性疾?。?。
二、研究方法
1.血清HBVM檢測:血清HBVM(HBsAg、HBsAb、HBeAg、HBeAb、HBcAb)定性采用酶聯(lián)免疫吸附試驗(ELISA)的方法檢測,試劑為上海實業(yè)科華公司生產(chǎn);定量采用時間分辨免疫熒光分析法測定。
2.HBV DNA檢測:采用實時熒光定量PCR法檢測,試劑為深圳匹基生物工程公司生產(chǎn)。
3.肝功能檢測:采用日本生產(chǎn)的OLYMPUSAU-2700型全自動生化分析儀檢測。
4.HGF的檢測:采用ELISA法檢測:HGF試劑盒購自美國R&DSystems。
5.統(tǒng)計學分析:所有數(shù)據(jù)采用SPSS11.5統(tǒng)計軟件包進行處理。正態(tài)分布資料采用均數(shù)±標準差(xˉ±s)表示。偏態(tài)分布資料采用中位數(shù)±四分位數(shù)間距(M±Q)表示。兩個樣本之間的相關(guān)性分析,采用Spearman等級相關(guān)分析。采用雙側(cè)檢驗,檢驗水準а=0.05。
一、CHB組和健康對照組血清HGF水平的比較見表1,CHB組各臨床類型組和健康對照組血清HGF水平的比較見表2。
二、CHB各臨床類型組相互之間HGF水平的比較(表3)。
三、高及低病毒載量組血清HGF水平比較(表4)。
四、HbeAg+CHB、HBeAg﹣CHB組高及低病毒載量間HGF水平比較(表5)。
五、炎癥活動組HbsAg載量高、低間HGF水平比較(表6)。
六、炎癥活動CHB組HGF與肝功能各指標、HBV-DNA的相關(guān)性分析(表7)。
1984年,Nakamura等從肝部分切除術(shù)的大鼠血清中分離到一種能刺激原代培養(yǎng)的肝細胞生長和DNA合成的肝源性因子,并首次將它命名為肝細胞生長因子(HGF)[5-6];此外,在大鼠的血小板、肝部分切除病人的血清、肝衰竭病人的血漿中也分離到類似物質(zhì)。在正常肝內(nèi),星狀細胞是最主要的HGF的來源;急性肝損傷后,竇狀上皮細胞、枯否氏細胞也能產(chǎn)生HGF[7];HGF以旁分泌、并可能以內(nèi)分泌的方式刺激各類上皮細胞的生長[1],是體外試驗中肝細胞生長和DNA合成最強有力的刺激因子[8~9]。HGF的促有絲分裂效應(yīng)也在體內(nèi)得到證實[10~11],在普通小鼠和肝臟部分切除的小鼠,注射HGF都能刺激肝細胞有絲分裂指數(shù)的數(shù)倍增加,促進蛋白合成、增加肝臟mRNA的含量和血清白蛋白的水平[1]。
表1 CHB組和健康對照組血清HGF水平的比較(M±Q,pg/ml)
表2 慢性乙型肝炎各臨床類型組和健康對照組血清HGF水平的比較(M±Q,pg/ml)
表3 CHB各臨床類型組之間HGF水平的比較(M±Q,pg/ml)
表4 高、低病毒載量組HGF水平比較(M±Q,pg/ml)
表5 HbeAg+CHB、HBeAg﹣CHB組高、低病毒載量間HGF水平比較(M±Q,pg/ml)
表6 HbsAg載量高、低組HGF水平比較(M±Q,pg/ml)
表7 炎癥活動組HGF水平與肝功能指標、HBV-DNA水平的相關(guān)性分析
本研究中,我們發(fā)現(xiàn),慢性HBV感染各臨床類型組血清HGF水平均較正常對照組明顯升高,差異有統(tǒng)計學意義,濃度在肝衰竭組>HBeAg-CHB組>HbeAg+CHB組>抗病毒組,肝衰竭組HGF濃度與其余各組比較,差異均有顯著性;在炎癥活動組(HbeAg+CHB組、HBeAg-CHB組、肝衰竭組),HGF與ALT、AST、TB均呈正相關(guān),特別是與TB相關(guān)系數(shù)達0.76;HGF與HbsAg載量高、低無相關(guān)性;與HBV-DNA載量無相關(guān)性。分析原因,考慮為肝臟炎癥活動時,在各種炎性因子的刺激下,肝星狀細胞被激活,產(chǎn)生大量HGF,刺激肝細胞增殖。此外,肝細胞產(chǎn)生的胰島素樣生長因子(IGF-1)也能刺激星狀細胞產(chǎn)生HGF。在肝損傷緩解后,激活的星狀細胞可自發(fā)逆轉(zhuǎn),HGF水平降低。因此,臨床上可把血清HGF作為肝損傷的指標之一[12],張遷[13]等人的研究也提示HGF值的變化不僅與血清TbiL值呈正相關(guān),而且亦可作為判斷病情及估計預后的參考指標。
本研究中,抗病毒組HGF水平低于HBeAg-CHB組,差異有顯著性。分析原因,可能為抗病毒治療后,炎癥緩解,產(chǎn)生HGF的間質(zhì)細胞減少,從而表現(xiàn)為血清HGF水平的下降。在動物肝損傷模型中,不論是D-半乳糖還是硫代乙酰胺誘導的肝損傷,攜帶HGF基因的轉(zhuǎn)基因鼠肝損傷都要比對照組輕,HGF的保護作用也許是通過PGE2的合成增多而實現(xiàn)的[2-3]。但是Barreiros[14]等也認為,由HGF產(chǎn)生的肝細胞生存信號的加強也許是HBV持續(xù)感染的危險因素。
肝衰竭在我國曾命名為重型肝炎,其病理變化特點為肝細胞發(fā)生廣泛壞死,病死率高達60%以上,肝衰竭確切發(fā)病機制尚未完全清楚。本研究肝衰竭組HGF水平高達5912.0±4497.0 pg/ml,分析其急劇增高的原因為血清中的HGF清除主要依靠有活性的肝實質(zhì)細胞,肝衰竭患者由于肝臟的代謝功能減低,不能有效地將血液中的HGF清除,加之一些炎性因子的濃度升高,刺激非實質(zhì)肝細胞不斷合成HGF,因此導致血清HGF的含量升高,而且隨著病情的發(fā)展而進行性升高[14]。提示我們,肝衰竭病人使用HGF的時期仍需進一步研究。
綜上所述,伴隨者肝損傷的發(fā)生和發(fā)展,肝臟間質(zhì)細胞活化,產(chǎn)生HGF,修復肝損傷。HGF、多種細胞因子互相作用,與機體、病毒因素一起共同影響著慢性HBV感染的過程和結(jié)局。如何利用HGF預防和治療肝損傷,應(yīng)用的時機,以及HGF與臨床的關(guān)系都值得進一步研究。
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The study of the clinical significance of HGF of serum in chronic hepatitis B.
CHAO Chun-mei,WEI Jia,YANG Wei-bo(1.Dept.of Infectious Diseases,The 1st Affiliated Hospital of Kunming Medical College;2.The Fourth Affiliated Hospital ofKunmingMedical College,KunmingYunnan 650032,China)
ObjectiveTo measure the levels of hepatocyte growth factor(HGF)in serum of different clinical types of chronic hepatitis B and analyze them trying to find a relationship with different clinical types,the levels of liver function,HBVMand HBVDNA,probing the clinical significance of HGF in the treatment of chronic hepatitis B. MethodsThe levels of HGF in serum of 78 subjescts with chronic hepatitis had been measured with ELISA.20 with normal liver function healthy subjects whose HGF also had been measured were chosen as the contrast group. Meanwhile,all the subjects had been measured about their liver function,HBsAg,HBsAb,HBeAg,HBeAb,HbcAb and HBV-DNA,and some patients'HbsAg levels and PT also had been measured.ResultsThe levels of HGF in chronic hepatitis B group were(929.10±1932.15)pg/ml,while in the healthy control group,the levels of HGF were (215.1±65.97)pg/ml.These two data had statistically significant difference.In Anti-virus group,HbeAg+CHB group,HBeAg﹣CHB group and liver failure group,the levels of HGF were(658.20±178.20)pg/ml,(772.60±335.40) pg/ml,(958.80±1005.49)pg/ml and(5912.0±4497.0)pg/ml.The levels of HGF in these groups were all higher than that ofhealthycontrol group(P<0.0125).The level ofHGF in the liver failure group was the highest compared with the other four groups,and the difference was statistically significant(P<0.008).The level of HGF in HBeAg-CHB group>the level of HGF in Anti-virus group and the differences were statistically significant(P<0.008).The level of HGF in HBeAg﹣CHB group>the level in HbeAg+CHB group and the level of HGF in HbeAg+CHB group>the level of HGF in Anti-virus group,but the difference was not statisticallysignificant(P>0.008).The levels ofHGF in high and low viral loadgroups were(2 141.0±3115.3)pg/ml and(812.50±639.80)pg/ml respectively,there was no statistically significant difference(P>0.05).The level of HGF of the load of HbsAg in the high and lowgroups were (1 258.0±2813.3)and(1 794.09±5 033.0)pg/ml,there was no different statistical significance.HGF and Tbil had a high degree of positive correlation.In the relationship between HGF and HBV-DNA tested by the Spearman rank correlation,the correlation coefficient was not statistically significant(P>0.05).The HGF and inflammatory activity of chronic HBV infection showed a high degree of positive correlation,and the correlation coefficient was statistically significant(P<0.05).Conclusion1.HGFs in different types ofchronic hepatitis B are significantlyhigher in serum, indicatingthat HGF has involved in the immune response,liver injuryand reconditioningtoHBV infection process;2. The levels of HGF in hepatic failure group are significantly higher than that of the rest of the clinical types,which showthat abnormal increasing of the levels of HGF might be related to one of the reasons of hepatic failure.In addition,the role of HGF in the treatment of liver failure needs further evaluation;3.HGFs are related to the degree of liver injury,and have nosignificant correlation with the loads ofHBV-DNAand HbsAg.
Chronic hepatitis B;Hepatocyte growth factor
R512.6
A
1006-4141(2012)04-342-05
2012-02-17
2012-03-21
晁春梅(1971~)女,云南祿豐人,醫(yī)學碩士,主治醫(yī)師,主要從事感染性疾病的臨床和教學工作。
韋嘉,E-mail:wejia@yahoo.cn