【作者】 石运莹；

【导师】 董怡；

【作者基本信息】 中国协和医科大学 ， 临床医学， 2008， 博士

【摘要】 目的前瞻性研究熊去氧胆酸(ursodeoxycholic acid,UDCA)、UDCA联合泼尼松龙两种治疗方案对原发性胆汁性肝硬化(primary biliary cirrhosis,PBC)的治疗效果,分析PBC患者肝脏生化指标、血清免疫球蛋白、外周血淋巴细胞亚群、细胞因子、抗线粒体抗体(anti-mitochondrial antibody,AMA)、抗M2亚型的抗线粒体抗体(AMA—M2)、抗GP210抗体和抗SP100抗体的临床相关性及其在两药物治疗后的变化特点。方法30例PBC患者(男1例,女29例,年龄由33至72岁,平均年龄52.33±8.77岁),均已接受UDCA(20人)或UDCA联合泼尼松龙(10人)治疗至少2年。根据当前治疗方案分为UDCA组(U组,20人)和UDCA联合泼尼松龙组(UP组,10人),PBC患者入选标准符合美国肝脏病学会2000年制定的PBC诊疗指南;入选研究患者签署知情同意书。治疗药物剂量为UDCA 13-15mg/kg/d;泼尼松龙起始剂量0.5mg/kg/d,4周开始减量,减至7.5mg/d时维持。于治疗前采集详细的临床及实验室资料,在治疗后第3、6、24月随访病人,动态检测肝脏生化指标(包括ALT、AST、GGT、ALP、TBIL、DBIL、TBA、ALB),白细胞计数(WBC),血清IgG、IgA、IgM,外周血淋巴细胞亚群(包括B细胞、NK细胞、T细胞、CD3+CD4+T细胞、CD3+CD8+T细胞、CD4+CD28+T细胞、CD4+CD28—T细胞、CD8+CD28+T细胞、CD8+CD28-T细胞、CD4+CD25+T细胞)、血清细胞因子(包括TNF—α、IL—1β、IL—2、IL—4、IL—6、IL—10)及自身抗体(AMA、AMA-M2、抗GP210抗体、抗SP100抗体)的水平。结果U组和UP组患者在治疗后肝生化指标ALT(分别为P=0.001和P=0.016)、AST(U组P=0.009)、ALP(UP组P=0.018)、GGT(UP组P=0.027)均有所下降。治疗后3个月时,U组ALT、ALP下降迅速且明显低于UP组(分别为P=0.016和P=0.039),此后差异消失。不同治疗组PBC患者血清IgG、IgA、IgM水平,外周血白细胞计数以及淋巴细胞亚群在治疗前后均无明显变化(P＞0.05)。不同治疗组PBC患者血清IL-2、IL-4、IL-6、IL-10、TNF-α、IL-1β水平都随治疗时间的延长而降低,尤其在治疗后24个月以上时下降最为明显(P＜0.05)。自身抗体检测结果显示,30例患者中AMA阳性率90%;AMA-M2阳性率73.33%;血清AMA滴度、AMA-M2水平在治疗后无明显改变(P＞0.05)。抗GP210抗体和抗SP100抗体表达阳性率分别为33.3%和16.67%。抗GP210抗体阴性组PBC患者的ALT、AST、ALP和IgM指标随着治疗时间的延长而逐渐降低(分别为P=0.000,P=0.000,P=0.014,P=0.039)。抗SP100抗体阴性组患者ALT、AST、ALP和GGT在治疗后明显降低(分别为P=0.007,P=0.015,P=0.005,P=0.048)。相关性分析显示,PBC患者肝脏ALT、AST、ALP和GGT指标与细胞因子IL-1β,IL-2,IL-6,IL-4,IL-10等指标间均具有不同程度正相关(P＜0.05)。细胞因子IL-1β和IL-10水平与淋巴细胞比例、CD8+CD28+T细胞比例之间均具有较好的正相关,与CD8+CD28-T细胞比例之间呈较好的负相关(P＜0.05)。抗GP210抗体水平与AST、DB、TBA、IgA、IgM之间均呈明显的正相关(P＜0.05),抗SP100抗体与IgG水平之间均呈现较好的负相关(P＜0.05)。结论1、UDCA单药治疗和UDCA与泼尼松龙的联合治疗均可缓解PBC患者部分异常的肝脏生化指标,在考虑治疗副作用的情况下UDCA单药治疗仍为PBC的首选方案;2、两种治疗方案对PBC患者外周血中免疫球蛋白、Th1、Th2型T淋巴细胞,CD8+CD28—调节T细胞、CD4+CD25+调节T细胞、NK细胞和B细胞均无明显调节作用;3、两种治疗方案均有缓慢抑制Th1型细胞因子IL-2表达的作用,IL-2水平低表达可抑制T淋巴细胞的活化效应;4、两种治疗方案均有缓慢抑制PBC患者Th2型细胞因子IL-4、IL-6、IL-10水平的作用,这类细胞因子水平下降可降低对B细胞活化效应,抑制过高的体液免疫反应对自身组织的损伤;5、两种治疗方案均能缓慢抑制PBC患者炎性细胞因子TNF-α与IL-1β水平的表达,PBC患者Th2型细胞因子与炎性细胞因子水平的降低,可抑制患者体内单核巨嗜细胞增殖活化,缓解患者肝脏内小叶间胆管的免疫炎症病理损伤;6、血清AMA、AMA-M2是PBC患者标志性抗体,但与病情轻重无关;抗GP210抗体与与PBC患者病情相关,可用于评估疾病严重度;抗GP210抗体和抗SP100抗体阳性的患者对药物治疗反应不佳,提示它们对于预测药物疗效有一定临床价值。更多还原

【Abstract】 Objective To prospectively study the therapeutic effects of ursodeoxycholic acid（UDCA） and UDCA combined with prednisolone in patients with primary biliary cirrhosis（PBC）,and analyze the expression characteristic of biochemical determinations, serum immunoglobulins,peripheral blood lymphocyte subsets,cytokines,and autoantibodies （anti-mitochondrial antibody,M2 anti-mitochondrial antibody,anti-GP210 antibodies and anti-SP100 antibodies） after treatment.Methods 30 patients（1 man and 29 women,aged from 30 to 72,average aged at 52.33±8.77） were included according to the guideline for management of PBC presented by AASLD in 2000,who all signed informed consent before treatment.All patients had been treated with UDCA（Group U,20 patients） or UDCA combined with prednisolone（Group UP,10 patients） for at least 2 years.The drug dosage of UDCA was 13-15mg/kg/d,and that ofprednisolone was 0.5mg/kg/d in the beginning,then gradually decreased to7.5mg/d since the 4^th week.Clinical and laboratory data of these patients were collected before the treatment,3 months,6 months and over 24 months after treatment,including liver biochemical function（including ALT、AST、GGT、ALP、TBIL、DBIL、TBA、ALB）,white blood cells,immunoglobulins（including IgG、IgA、IgM）, lymphocytic subsets（including B cells,NK cells,T cells,CD3+CD4+T cells,CD3+CD8+ T cells,CD4+CD28+T cells,CD4+CD28-T cells,CD8+CD28+T cells,CD8+CD28 -T cells,CD4+CD25+T cells）,cytokines（including TNF-α,IL-1β,IL-2,IL-4,IL-6, IL-10） and autoantibodies（AMA,AMA-M2,anti-GP210 antibody,anti-SP 100 antibody）. Results The levels ofALT（P=0.001 in group U;P=0.016 in group UP）,AST（P=0.009 in group U）,ALP（P=0.018 in group UP） and GGT（P=0.027 in group UP） decreased in both group U and group UP after treatment.The levels of ALT and ALP in group U decreased rapidly and were obviously lower than that in group UP（P=0.016 and P=0.039 respectively） after three-month treatment.The above difference disappeared as the treatment went on. There was no significant change in the levels of IgG,IgA,IgM,WBC and lymphocytic subsets in either group U or group UP after treatment（P＞0.05）.The levels of IL-2,IL-4, IL-6,IL-10,TNF-αand IL-1βin the peripheral blood of patients with PBC decreased in both group U and group UP as time went by（P＜0.05）,which was especially significant when the time of therapy was over 24 months.Among the 30 patients,90%of the patients were detected with positive AMA and 73.33%with AMA-M2.There was no significant change in the titer of AMA or the level of AMA-M2 in either group after treatment（P＞0.05）.33.3% and 16.67%of patients had positive anti-GP210 antibody and anti-SP100 antibody, respectively.The levels of ALT,AST,ALP and IgM among patients with negative anti-GP210 antibody gradually decreased after treatment（P=0.000,P=0.000,P=0.014 and P=0.039,respectively） as time went by.The levels of ALT,AST,ALP and GGT among patients with negative anti-SP100 antibody decreased significantly after treatment（P=0.007, P=0.015,P=0.005 and P=0.048,respectively） as time went by.Correlation test showed that levels of ALT,AST,ALP and GGT were correlated positively with different cytokines on certain level（P＜0.05）.The levels of IL-1βand IL-10 were correlated positively with the percentages of lymphocytes and CD8+CD28+T cells while negatively with the percentage of CD8+CD28-T cells（P＜0.05）.There was a positive correlation between anti-GP210 antibody and the levels of AST,DB,TBA,IgA and IgM（P＜0.05）,while a negative correlation appeared between anti-SP 100 antibody and the level of IgG（P＜0.05）. Conclusions 1.Both UDCA monotherapy and UDCA combined with prednisolone could improve part of the liver function of the patients with PBC.Considering the side effects, UDCA monotherapy is still the first-choice treatment.2.There is no regulative effect of the two therapies on expressions of immunoglobulins,Th1 and Th2 lymphocytes,CD8+CD28 -regulatory T cells,CD4+CD25+ regulatory T cells,NK cells and B cells in patients with PBC.3.Both of the two therapies could slowly inhibit the levels of Th1 cytokine-IL-2, and low-level IL-2 could inhibit the activation of T lymphocytes.4.Both of the two therapies could slowly inhibit the levels of Th2 cytokines-IL-4,IL-6,IL-10,and their decrease could inhibit the activation of B cells and the lesions due to higher immune reactions to autoantigens.5.Both of the two therapies could slowly inhibit the levels of TNF-αand IL-1β,and the reduction of TNF-αand IL-1βmight relieve the inflammatory injury of the liver,suppress the inflammatory reaction and delay the pathological lesions of the liver.6.AMA,AMA-M2 is the biomarker of PBC,but there is no relationship between them and the states of the illness.There is a relationship between anti-GP210 antibodies and the state of PBC,and the level of anti-GP210 antibodies could be used to assess the severity of PBC.Patients with positive anti-GP210 antibody and anti-SP100 antibody have bad reaction towards drug therapy,thus they could be used for prediction of the therapeutic effects.更多还原