乙型肝炎病毒相关慢加急性肝功能衰竭患者外周血中皮质醇水平变化

Change of peripheral blood cortisol concentration in patients with hepatitis B virus-related acute-onchronic liver failure

目的了解HBV相关慢加急性肝功能衰竭（ACLF）患者外周血中皮质醇水平与病情严重程度的关系及其对预后的评价。方法HBV相关ACLF患者45例，其中早、中、晚期各15例；重度慢性乙型肝炎患者15例。应用化学发光法检测患者外周血中皮质醇浓度。比较各组血清皮质醇浓度，并将皮质醇浓度与PTA、TBil、Alb、ALT、AST、HBV DNA、国际标准化比值（INR）等及终末期肝病模型（MELD）评分进行相关性分析。应用Logistic回归分析筛选对HBV相关ACLF患者预后有影响的独立危险因素。结果重度慢性乙型肝炎组和ACLF早期组、中期组、晚期组外周血皮质醇浓度分别为（595．6±114．0）、（496．0±87．2）、（303．9±81．1）和（183．8±71．8）nmol／L，呈逐渐递减趋势，各组问比较差异有统计学意义（F＝63．93，P〈0．01）。外周血皮质醇浓度以MELD〈C30分组最高，其次为30～40分和〉40分组，各组问比较差异均有统计学意义（F＝9．01，P〈0．01）。ACLF患者外周血皮质醇浓度与PTA呈正相关（r＝0．83，P〈0．01），与TBil（r＝0．34，P〈0．05）、MELI）评分（r=-0．60，P〈0．01）、AST/ALT（r=0．35，P〈0．05）、INR（r=0．59，P〈0．01）均呈负相关，而与Alb、ALT、AST、HBVDNA载量无关。多因素Logistic回归分析结果显示，MELD评分、皮质醇、Alb及总胆固醇足影响HBV相关ACLF患者预后的独立危险因素。ACLF患者存活组血清皮质醇浓度高于死亡组。结论HBV相关ACLF患者外周血皮质醇水平降低，皮质醇水平与患者肝脏功能损害程度、病情严重程度和预后有关，皮质醇浓度低预示患者短期预后不佳。

Objective To study the profile of peripheral blood cortisol concenlration in patients with hepatitis B virus （HBV） related acute-on-chronic liver failure （ACLF） and its association with disease severity and predictive value on prognosis. Methods Forty five patients with HBV-related ACLF, including 15 patients in early stage, 15 in medium-stage and 15 in end stage; and 15 patients with severe chronic hepatitis 13 （CHB） were also enrolled. Peripheral blood cortisol concentration was tested by chemiluminesence immunoassay. SPSS version 18.0 was used to compare peripheral blood cortisol concentration among different groups and analyze its correlation with prothrombin activity （PTA）, total bilirubin （TBil）, albumin （AIb）, alanine aminotransferase （ALT）, aspartate aminotransferase （AST）, HBV DNA, international normalized ratio （INR） and model for end-stage liver disease （MELD） scores. The independent risk factors of prognosis in patients with HBV related ACI.F were determined by performing Logistic regression analysis. Results The concentrations of peripheral blood cortisol in severe CHB group, early-stage ACLF group, medium-stage ACLF group and end-stage ACLFgroup were （595.6±114.0）, （496.0±87.2）, （303.9±81. 1）, and （183.8± 71.8） nmol/L, respectively. A decreasing trend was observed and the differences among groups were statistically significant （F= 63. 93, P 〈 0. 01 ）. Peripheral blood cortisol concentration were significantly different among subgroups of patients with MELD〈30, followed by 30--40 and 〉40 （F= 9.01, P〈0.01）. Peripheral blood cortisol concentration in patients with ACLF was positively correlated with PTA level （r=0.83, P〈0.01）, and inversely correlated with TBil （r=-0.34, P〈 0.05）, MEI.Dscore （r= 0. 60, P〈0.01）, AST/ALT （r=-0. 35, P〈0.05）, and INR （r=-0.59, P〈0.01）. Association with Alb, ALT, AST and HBV DNA was not observed. According to muhivariate Logistic regression analysis, MELD score, cortisol level, Alb and total cholesterol were independent risk factors of prognosis for patients with ACLF. Serum cortisol concentration in survival group of HBV related ACLF was higher than that in death group, while the death group exhibited a gradually decreasing trend. Conclusions The peripheral blood cortisol concentration decreases in patients with HBV related ACLF, which is related to the degree of liver dysfunction, disease severity and prognosis of patients. Moreover, the lower level of cortisol concentration indicates poor short term prognosis in patients with HBV related ACLF.