HBV相关慢加急性肝衰竭患者糖皮质激素受体表达特征及其与疗效的关系

Expression features of glucocorticoid receptor and its association with treatment outcome in patients with hepatitis B virus-related acute-on-chronic liver failure

目的探讨糖皮质激素(GC)治疗早期和中期HBV相关慢加急性(亚急性)肝衰竭(HBV-ACLF)患者时激素受体(GR)及其亚型α、β的表达特征与激素治疗敏感性的关系。方法采用前瞻性、非随机对照研究方法入组2015年9月-2018年6月北京佑安医院住院治疗的33例早、中期HBV-ACLF患者,其中激素组18例在内科综合治疗基础上给予甲基强的松龙静点7 d。采用流式细胞检测仪和逆转录PCR(RT-PCR)检测GR及GR-αmRNA、GR-βmRNA表达情况,观察基线、8 d GR及其亚型表达差异。激素组患者根据10 d时GC疗效分为激素敏感组(13例)和激素不敏感组(5例),分析不同组别GR及其亚型表达的特征与GC治疗敏感性的关系。计量资料2组间比较采用两独立样本t检验,自身前后对照比较采用配对t检验;计数资料2组间比较采用确切概率法检验。28 d生存情况采用Kaplan-Meier生存曲线进行分析,2组间比较采用log-rank检验。结果激素组患者使用激素后8 d时GR-αmRNA表达水平[(0.99±0.48)×10^-2)]较基线[(1.96±0.50)×10^-2)]明显降低(t=6.586,P<0.001)。激素组与非激素组患者第8 d时GR-αmRNA表达[(0.99±0.48)×10^-2vs(1.70±0.66)×10^-2]差异有统计学意义(t=-3.518,P=0.001);激素敏感与不敏感组8 d时比较,激素敏感组GR-αmRNA表达水平[(1.21±0.34)×10^-2]明显高于激素不敏感组[(0.43±0.31)×10^-2](t=4.456,P<0.001);且8 d时激素敏感组GR-αmRNA表达降低幅度明显小于激素不敏感组(t=-2.904,P=0.01)。GR-βmRNA表达水平8 d时激素敏感组[(0.14±0.08)×10^-2]与激素不敏感组[(0.10±0.04)×10^-2]差异无统计学意义(t=1.092,P=0.291)。8 d时激素组患者GR-αmRNA表达降低幅度与基线的比值均值为46%,据此分为≤46%组(10例)和>46%组(8例)。2组GR-αmRNA表达水平降低幅度与基线的比值差异显著(26.99%±25.09%vs 70.09%±16.08%,t=-4.203,P=0.001)。10 d时,TBil降低幅度与基线比值在≤46%组和>46%组间差异显著(P=0.021);10 d时,PTA上升幅度与基线比值在≤46%组和>46%组间差异显著(P=0.048)。结论HBV-ACLF早、中期患者使用GC后GR-αmRNA表达水平明显降低,激素敏感组患者GR-αmRNA水平较基线降低幅度小,且28 d TBil和PTA指标改善优于激素不敏感组,GR-αmRNA动态变化对激素疗效具有一定参考价值。

Objective To investigate the expression features of glucocorticoid receptor(GR)and its subtypesαandβin patients with early-or middle-stage hepatitis B virus-related acute/subacute-on-chronic liver failure(HBV-ACLF)treated by glucocorticoid(GC)and their association with sensitivity to glucocorticoid therapy.Methods A prospective non-randomized controlled trial was performed for 33 patients with early-or middle-stage HBV-ACLF who were hospitalized and treated in Beijing YouAn Hospital from September 2015 to June 2018,and among these patients,18 received intravenous infusion of methylprednisolone for 7 days in addition to comprehensive medical treatment.Flow cytometry and RT-PCR were used to measure the mRNA expression of GR,GR-α,and GR-β,and the expression of GR,GR-α,and GR-βwas observed at baseline and on day 8.According to the response to GC on day 10,the hormone group was further divided into hormone-sensitive group with 13 patients and hormone-insensitive group with 5 patients.The two-independent-samples t test was used for comparison of continuous data between two groups,and the paired t-test was used for comparison within one group before and after treatment;the Fisher’s exact test was used for comparison of categorical data between groups.The Kaplan-Meier survival curve was used to analyze 28-day survival,and the log-rank test was used for comparison between groups.Results The hormone group had a significant reduction in the mRNA expression of GR-αon day 8 after hormone administration[(0.99±0.48)×10^-2 vs(1.96±0.50)×10^-2,t=6.586,P<0.001]There was a significant difference in the mRNA expression of GR-αbetween the hormone group and the non-hormone group on day 8[0.99±0.48)×10^-2 vs(1.70±0.66)×10^-2,t=-3.518,P=0.001]On day 8,the hormone-sensitive group had significantly higher mRNA expression of GR-αthan the hormone-insensitive group[1.21±0.34)×10^-2 vs(0.43±0.31)×10^-2,t=4.456,P<0.001]and the hormone-sensitive group had a significantly greater reduction in the mRNA expression of GR-αcompared with the hormone-insensitive group(t=-2.904,P=0.01).There was no significant difference in the mRNA expression of GR-βon day 8 between the hormone-sensitive group and the hormone-insensitive group[0.14±0.08)×10^-2 vs(0.10±0.04)×10^-2,t=1.092,P=0.291]For the hormone group,the mean ratio of reduction in GR-αmRNA expression to baseline value was 46%on day 8,and according to this,the patients were divided into≤46%group with 10 patients and>46%group with 8 patients.There was a significant difference in the ratio of reduction in GR-αmRNA expression to baseline value between the two groups(26.99%±25.09%vs 70.09%±16.08%,t=-4.203,P=0.001).On day 10,there were significant differences between the≤46%group and the>46%group in the ratio of reduction in total bilirubin(TBil)to baseline value(P=0.021)and the ratio of increase in prothrombin time activity(PTA)to baseline value(P=0.048).Conclusion In patients with early-or middle-stage HBV-ACLF,there is a significant reduction in the mRNA expression of GR-αafter GC treatment.Patients sensitive to hormone have a relatively low degree of reduction in the mRNA expression of GR-α,with better improvements in TBil and PTA on day 28 than those insensitive to hormone.Dynamic change of GR-αmRNA has a certain reference value in predicting the outcome of hormone therapy.