经颈静脉肝内门体静脉分流术降低门静脉高压对外周免疫细胞的影响及免疫变化与肝性脑病的关系

The effect on peripheral immune cells and the relationship between immune changes and hepatic encephalopathy following the decreasing of portal hypertension by transjugular intrahepatic portosystemic shunt

目的本研究旨在分析经颈静脉肝内门体静脉分流术(transjugular intrahepatic portosystemic shunt,TIPS)降低门静脉高压对外周免疫细胞的影响及免疫变化与肝性脑病的关系。方法收集2020年10月—2022年10月在解放军总医院第五医学中心行TIPS治疗的39例肝硬化患者的临床资料,包括TIPS术前、术后1周及术后12周的实验室检查结果,以及肝性脑病的发生情况,分析外周免疫细胞的变化情况及其与肝性脑病的相关性。结果与基线相比,TIPS术后1周,白细胞(white blood cell,WBC)、中性粒细胞绝对值(absolute neutrophil cell,ANC)、单核细胞绝对值(absolute monocytes cell,AMC)、CD8+T细胞水平均升高,差异有统计学意义(P均<0.05);术后12周,WBC、CD8+T细胞、T淋巴细胞水平均升高,差异有统计学意义(P均<0.05)。单因素Logistic回归分析表明,年龄≥57岁(P=0.020)、TIPS术后1周丙氨酸氨基转移酶(alanine aminotransferase,ALT)≥1 ULN(正常上限值)(P=0.041)、TIPS前中度贫血(P=0.083)和TIPS术后1周ANC<1 ULN(P=0.051)可能是肝性脑病发生的危险因素。将上述因素纳入多因素Logistic回归分析,结果显示年龄≥57岁(OR=8.333,95%CI:1.474~47.114)、TIPS术后1周ALT≥1 ULN(OR=7.433,95%CI:1.257~43.949)是肝性脑病发生的风险因素,TIPS术后1周ANC<1 ULN(OR=0.140,95%CI:0.025~0.987)是肝性脑病发生的保护因素。使用受试者工作特征(receiver operatingcharacteristic,ROC)曲线评估预测准确性,结果提示TIPS术后1周ANC<1 ULN的ROC曲线下面积为0.835(95%CI:0.695~0.974,P=0.000),提示具有较显著的预测价值。结论WBC、CD8+T细胞水平在TIPS术后1周及12周增加;ANC、AMC水平在TIPS术后1周增加,术后12周恢复。中性粒细胞绝对值的早期变化可以预测肝性脑病的发生。

Objective The purpose of this study was to analyze the effect on peripheral immune cells and the relationship between immune changes and hepatic encephalopathy following the decreasing of portal hypertension by Transjugular intrahepatic portosystemic shunt(TIPS).Methods Clinical data were collected from 39 patients who were diagnosed with cirrhosis complicated with portal hypertension and varices and treated with TIPS at the Fifth Medical Center of PLA General Hosital from October 2020 to October 2022,these included the results of laboratory testsincluding the laboratory examination results at baseline,1 week after TIPS and 12 weeks after TIPS,as well as the occurrence of hepatic encephalopathy.The changes of peripheral immune cells and their correlation with the occurrence of hepatic encephalopathy were analyzed.Results Compared with baseline,the levels of white blood cell(WBC),absolute neutrophil cell(ANC),absolute monocytes cell(AMC),and CD8+T cells were increased at 1 week after TIPS,with statistically significant differences(P<0.05).At 12 weeks after TIPS,the levels of WBC,CD8+T cells,and T lymphocytes were increased,with statistically significant differences(P<0.05).Univariate Logistic regression analysis showed that age≥57 years(P=0.020),alanine aminotransferase(ALT)≥1 ULN(normal upper limit value)at 1 week after TIPS(P=0.041),moderate anemia before TIPS(P=0.083),and ANC<1 ULN at 1 week after TIPS(P=0.051)may be risk factors for the development of hepatic encephalopathy.When these factors were included in the multivariate Logistic regression analysis,the results showed that age≥57 years(OR=8.333,95%CI:1.474~47.114),ALT≥1 ULN at 1 week after TIPS(OR=7.433,95%CI:1.257~43.949)were risk factors for the occurrence of hepatic encephalopathy,and ANC<1 ULN at 1 week after TIPS(OR=0.140,95%CI:0.025~0.987)was protective factors for the occurrence of hepatic encephalopathy.The receiver operating characteristic(ROC)curve was used to evaluate the prediction accuracy,and the results showed that the area under curve of ANC<1 ULN at 1 week after TIPS was 0.835(95%CI:0.695~0.974,P=0.000),indicating significant predictive value.Conclusions Patients with portal hypertension exhibited an increase in WBC and CD8+T cell counts at 1 week and 12 weeks after TIPS;ANC and AMC counts increased at 1 week after TIPS and recovered at 12 weeks after TIPS.Early changes in absolute neutrophil count can predict the occurrence of hepatic encephalopathy after TIPS.