【作者】 张宁；

【导师】 凌昌全；

【作者基本信息】 第二军医大学 ， 中西医结合临床， 2012， 博士

【摘要】 背景肝纤维化是各种原因引起的肝脏疾病发展至终末期肝病的中间环节和必经阶段，有效地阻止肝纤维化进展或最大程度地逆转肝硬化能够减少终末期肝病的发生，从而降低肝病相关的病死率。中医药在肝纤维化的治疗方面具有独特的优势，复方鳖甲软肝片是基于肝纤维化的中医辨证指导，以“软坚散结,化瘀解毒,益气养血”为治则，以抗纤维化为主要功效的中药复方。上市前的多中心临床对照试验以“晚期乙肝肝纤维化和早期乙肝肝硬化”为研究对象，在未给予抗病毒治疗的情况下，通过治疗前后肝组织学纤维化分期对比，证实该药具有明确的抗纤维化作用，且疗效优于对照药物“和络舒肝片”。自核苷类药物用于乙肝的抗病毒治疗以来，大大降低了乙肝的慢性化进程，大量的研究证实有效的抗病毒治疗能够在某种程度上阻止或逆转肝纤维化。在这样的背景下，为最大限度地节约资源，优化中西医结合治疗方案，需要重新对复方鳖甲软肝片抗肝纤维化的疗效进行评价。尽管目前已有抗病毒治疗基础上使用复方鳖甲软肝片的临床研究报道，但仍存在些许不足，主要表现在：1、根据不同纤维化程度分层研究的临床随机对照试验较少，证据级别较高的系统评价比较缺乏；2、疗效评价指标多使用肝纤维化四项、肝功等与炎症密切相关的指标，缺少肝组织病理或与肝组织程度高度相关的无创性评价指标，由于肝组织活检存在创伤性、取样误差、费用昂贵、不易重复等缺点，无创性肝纤维化诊断及评价方法的建立和使用显得尤为迫切。近年来，此方面已经取得较大的进展，如瞬时弹性检测及各种无创性诊断模型的应用，但尚缺少更严谨的评价及应用。基于此，本课题首先从循证医学的角度对现有的“抗病毒治疗基础上使用复方鳖甲软肝片的随机对照试验”进行了meta分析，再以肝组织纤维化程度作为标准，对目前常用的几种无创性肝纤维化诊断方法进行相关回归分析，找出与肝组织程度高度相关的无创性诊断方法，在此基础上，将其作为主要疗效评价指标，设计临床随机对照试验，进一步对复方鳖甲软肝片进行疗效评价。目的1、对目前在抗病毒治疗基础上使用复方鳖甲软肝片抗乙肝肝纤维化方面的临床随机对照试验进行meta分析，探讨复方鳖甲软肝片抗肝纤维化的临床疗效。2、通过分析目前常用的无创性诊断方法与肝组织纤维化程度之间的相关性，寻找与肝纤维化程度高度相关、能够有效诊断和预测肝纤维化的诊断方法，作为疗效评价指标。3、设计临床随机对照试验，研究在恩替卡韦抗病毒治疗基础上，复方鳖甲软肝片治疗后对不同程度的纤维化即慢性乙型肝炎和代偿期肝硬化，在不同时间节点的疗效。方法1、从循证医学的角度，纳入“以慢性乙肝及乙肝肝硬化为研究对象，对照组口服核苷类药物抗病毒，试验组加用复方鳖甲软肝片抗纤维化治疗”的临床随机试验，使用Revman软件对文献中涉及的肝纤维化四项及HBVDNA和HBeAg阴转率进行meta分析。2、以肝组织学病理分级作为金标准，利用相关分析及多重线性回归分析的统计学方法，分析瞬时弹性成像检测（transient elastography,TE即FibroScan）、APRI预测模型、肝纤维化四项及其他临床常规检测指标与肝组织学纤维化之间的相关关系，建立各指标与纤维化程度之间的线性回归方程；利用受试者工作曲线下面积来验证高度相关的无创性诊断方法对肝脏纤维化程度诊断的准确性。3、以“有肝纤维化表现的慢性乙肝（CHB组）及代偿期乙肝肝硬化（LC组）患者”为研究对象，开展前瞻性随机对照试验研究，对照组仅使用恩替卡韦抗病毒治疗，试验组除使用恩替卡韦抗病毒治疗外，还联合使用复方鳖甲软肝片抗纤维化治疗，观察时间节点为6月和12月，主要疗效评价指标选用FibroScan结果FS和APRI，比较试验组和对照组治疗后各指标的变化情况及各组自身治疗前后各指标的变化情况，以判断抗病毒基础上加用复方鳖甲软肝片治疗的优势,同时对肝功、纤维化四项、HBVDNA、HBeAg阴转率进行比较。试验组与对照组之间计数资料的比较使用组间t检验，组内前后比较使用配对t检验的统计分析方法；计数资料的比较使用χ2检验。结果1、Meta分析结果提示：以CHB及LC患者为研究对象，复方鳖甲软肝片治疗后，在肝纤维化四项方面，降低CHB及LC患者的HA、LN、PCⅢ优于对照组，在降低LC患者的IV.C方面优于对照组；复方鳖甲软肝片在CHB患者的HBVDNA及HBeAg阴转方面与核苷类药物可能有协同作用。2、无创性肝纤维化诊断方法探索（1）以纤维化病理分期“S”为标准，相关分析结果提示：ALB、CHE、LDLC、PLT与S呈负相关，ALT、AST、DBIL、γ-GT、TBA、PT、FS、APRI、HA、LN、IV.C、PCⅢ与S呈正相关，其中，FS与S的相关系数最大（r=0.67）。多重线性回归分析结果提示：FS可以单独或联合γ-GT进入模型对S进行预测，它们之间存在多重共线性关系。（2）FS和APRI能够较准确预测实际的纤维化分期程度，诊断肝纤维化（S≧2），其AUROC分别为0.866，0.718，对应的FS和APRI为6.85，0.456；当S≧3，AUROC分别为0.87，0.733，对应的FS和APRI为9.95，0.469。3、随机对照试验结果（1）使用FS和APRI作为主要疗效评价指标，组间t检验结果提示：复方鳖甲软肝片治疗CHB与对照组比较，在降低FS方面，治疗6月时优于对照组，APRI无明显差异，延长治疗至12月FS与APRI与对照组比较均无明显差异；复方鳖甲软肝片治疗LC患者与对照组比较，在降低FS方面，治疗6月、12月时均优于对照组。降低APRI方面，治疗6月较对照组无明显差异，治疗12月优于对照组。各组自身前后配对t检验结果表明，FS和APRI在治疗6、12月与治疗前比较均有显著下降，在CHB患者，对照组与试验组治疗12月与治疗6月结果比较无显著差异，在LC患者，试验组在治疗12月FS和APRI的下降优于治疗6月。（2)肝纤维化四项方面，组间t检验提示：对CHB患者，试验组与对照组比较，在治疗6月、12月肝纤维化四项无明显差异；对LC患者，试验组与对照组比较，在治疗6月肝纤维化四项无明显差异，治疗12月LN、IV.C的下降优于对照组。各组自身前后配对t检验结果提示：肝纤维化四项在治疗6、12月与治疗前比较均有显著下降。（3）肝功方面，组间t检验提示：复方鳖甲软肝片治疗后，CHB患者在治疗6月AST下降优于对照组，治疗12月后ALT、AST下降优于对照组；LC患者在治疗6月肝功变化较对照组无明显差异，治疗12月后ALB、CHE的升高优于对照组，AST下降优于对照组，ALT、TBIL较对照组无明显下降。（4）联合使用复方鳖甲软肝片治疗在HBVDNA、HBeAg阴转率方面较对照组无明显变化。结论1、通过对抗病毒基础上使用复方鳖甲软肝片的随机对照临床试验进行meta分析，结果提示：复方鳖甲软肝片为有效的抗肝纤维化药物，在降低肝纤维化血清标志物方面优于对照组，在HBVDNA、HBeAg阴转率方面可能与核苷类药物有协同作用。2、通过无创性肝纤维化诊断指标与S的相关回归分析及准确性检验，提示：目前临床常用的几种无创性诊断方法中，FibroScan检测结果FS与肝组织纤维化程度S之间的相关性最大，多重线性回归结果提示FS可以单独用于肝纤维化的诊断和预测，通过计算AUROC，FS在诊断肝纤维化程度方面具有较高的准确性。3、临床随机对照试验提示：给予CHB及LC患者恩替卡韦抗病毒治疗后，肝纤维化的程度可有一定程度的减轻，联合复方鳖甲软肝片治疗后，能够更显著地降低主要疗效评价指标FS和APRI，对肝功也有一定的改善作用，但在HBVDNA、HBeAg阴转率方面未见明显变化。复方鳖甲软肝片的上述疗效与对照组比较，在CHB患者治疗6月体现明显，延长治疗至12月未见明显优势，在LC患者治疗6月及12月均有明显优势。更多还原

【Abstract】 BackgroundLiver fibrosis is the middle and essential stage of various liver diseases developedinto end stage,if liver fibrosis can be prevented from progress or liver cirrhosis can beregressed in the maximal degree,then the related mortality can be decreased.Traditionalchinese medicine play a unique role in the treatment of liver fibrosis,Fu Fang Bie JiaRuan Gan Pian is one of the effective formulas,which is established under the theory ofTCM differentiation of syndrome,its therapeutic principles of TCM are"softening andresolving hard masses,dissolving blood stasis and detoxication,replenishing qi and blood",anti-fibrosis is the chief efficacy.It has been demonstrated that FFBJRGP has a betterefficacy of anti-fibrosis than the control drug-He Luo Shu Gan Pian through multi-centerclinical control trials before listed,in which HBV-related advanced liver fibrosis and earlycirrhosis are involved,all these participants weren’t given anti-virus therapy.Chronic progress of hepatitis B has been delayed remarkably since nucleosideanalogs are used for anti-virus,studies have proved that effective anti-virus therapy canprevent and regress live fibrosis in some degree.In order to save resources and optimizethe integrate therapy of TCM and western medicine,we need to evaluate the efficacy ofFFBJRGP secondly on the basis of anti-virus therapy.Although there have been some reports about the FFBJRGP’s clinical efficacy basedon the anti-virus therapy, the following deficiencies still exist:there are less high levelclinical randomized control trials and systematic reviews,indexes of effective evaluationare restricted to "the four serum liver fibrosis marker,liver function,etc",which are morerelated to inflammation than fibrosis.the powerful evidence of liver histology or highercorrelation indexes aren’t put into practice,although non-invasive diagnosis such astransient elastography and other predictive models.Considering the drawbacks of liverbiopsy such as invasive operation,high price,and not easily been repeated and so on,non-invasive assessment method for diagnosis and evaluation are urgently needed.Inrecent years,many developments have been accepted in these areas,such as TE and othervarious non-invasive diagnostic models,however,more rigorous evaluations and uses arelacked.Under this condition,our study first make a meta analysis of the literatures accordingwith"randomized control trials about HBV-related liver fibrosis,FFBJRGP is used foranti-fibrosis on the basis of nucleoside analogs used as anti-virus",then some often used non-invasive indexes are assessed with the liver histology,at last we design the clinicalrandomized control study to further evaluate the efficacy.Objective1.Clinical efficacy of FFBJRGP was evaluated through meta analysis on the clinicalrandomized control studies which used nucleoside analogs as anti-virus treatment.2.Correlation and regression analysis between non-invasive diagnostic methods andliver histology was explored,in order to find effective and accurate method to diagnoseand predict the liver fibrosis.3.The clinical efficacy of FFBJRGP are evaluated based on clinical randomizedtrials,the participants included chronic hepatitis B and liver cirrhosis,the control grouponly use entecavir for anti-virus,experimental group add FFBJRGP for anti-fibrosis.thereare two observation time points through the treatment courses.Methods1.Meta analysis was made from the view of evidence-based medicine, literatures areinvolved into if they accord the following conditions:patients of chronic hepatitis B andHBV-related cirrhosis as participants,control group used nucleoside analogs as anti-virusdrug,experimental group added FFBJRGP as anti-fibrosis drug,two groups are randomlydistributed.Software of Revman is used for statistical analysis on the four fibrosisindexes and negative rates of HBVDNA and HBeAg.2.Correlation and multi-linear regression between histological stages andnon-invasive clincal indexes are studied by case analysis,including fibroscan’sresult,APRI predictive model,four fibrosis indexes and other clinical routine tests, theaccuracy between non-invasive diagnostic methods and stages of liver histology isestimated using area under receiver operating characteristics.3.Clinical efficacy of FFBJRGP is evaluated through prospective randomizedcontrol trial which involve patients diagnosed as chronic hepatitis B and livercirrhosis.The control group are treated with Entecavir as anti-virus drug,experimentalgroup are treated with Entecavir and FFBJRGP,the main outcome indexes are FS andAPRI based on Part2’s results,liver function and other serum fibrotic markers andHBVDNA and HBeAg negative rates are also compared. There are two observation timepoints which are6and12months after treatments.Two-sample t-test is used to comparecontinuous data between experimental group and control group after treatment,pairedt-test is used to compare the before and after treatment.numeration data use χ2-test. Result1.Meta analysis shows that,after treatment of FFBJRGP,experimental group of CHBand HBV-related liver cirrhosis achieve lower serum fibrotic markers such as HA、LN、PCⅢ, and lower IV.C in LC subgroup;with aspects of HBVDNA and HBeAg negtiverates, FFBJRGP may have synergistic effects with nucleoside analogs.2.(1)Correlation analysis shows indexes of ALB,CHE,LDLC,PLT have negtivecorrelation with stages of liver histology,indexes of AST,DBIL,γ-GT,TBA,PT,FS, APRI,HA,LN,IV.C,PCⅢ have positive correlation with stages of liver histology,among theseall,correlation coefficients between FS and S are maximal(r=0.67).Multi-linearregression analysis shows FS can singly or together with γ-GT enter into the regressionmodel to predict the stages of liver histology.(2)FS can predict and judge the degree ofliver fibrosis,comparing withe APRI, the AUROC are0.866,0.718when predicting S≧2,FS and APRI are6.85,0.456respectively.the AUROC are0.87,0.733when predicting S≧3,FS andAPRI are9.95,0.469respectively.3.(1)FS and APRI are used as the chief outcome to evaluate the efficacy ofFFBJRGP. FS in CHB is significantly lower than control group after6months’treatment,FS and APRI are both significantly lower than control group after6and12months’ treatment.(2)The LN and IV.C of the four fibrotic indexes in LC are significantlylower than control group after12months’ treatment.(3)AST in CHB is significantlylower than control group after6months’ treatment,ALT and AST in CHB are bothsignificantly lower than control group after12months’ treatment.AST in LC issignificantly lower than control group,ALB and CHE are higher,after12months’treatment.(4)There is no significant difference in HBVDNA and HBeAg’s negative rates.Conclusion1.Meta analysis suggests FFBJRGP is an effective anti-fibrotic traditional chineseformula,it can decrease serum fibrotic markers more significant than control group whichdidn’t use FFBJRGP,it can improve the effects of nucleoside analogs in negative rates ofHBVDNA and HBeAg.2.The result of FibroScan called as FS have the highest correlation coefficient withstages of liver histology, which can be used to diagnose and predict liver fibrosissingly,there is high accurate when FS used to diagnose liver fibrosis through calculateAUROC.3.Clinical randomized research shows that FFBJRGP can decrease FS and APRI more significantly compared to control group which used Entecavir only, it can improveliver function in some degree,it didn’t have synergistic effects with entecavir on negativerates of HBVDNA and HBeAg through our study.In CHB patients,there is no significantdifference in6or12months treatment, In compensated LC patients,experimental grouphave better results both in6and12months.更多还原