严重肝病表型的肝豆状核变性患者的临床与遗传特征分析

Analysis of clinical and genetic characteristics of the severe liver disease phenotype in patients with hepatolenticular degeneration

目的探讨肝豆状核变性(HLD)患者严重肝病表型的临床和遗传特征及其预测模型。方法以1989年1月至2022年12月在上海交通大学医学院附属新华医院确诊的HLD住院患者为研究对象,根据受累器官进行临床分型,将有肝病表型者归于肝病组并进一步分为严重肝病组和普通肝病组。比较各组患者临床特征及基因变异,多元回归分析严重肝病患者的预测指标。据资料不同采用t检验、Mann-Whitney U检验或χ^(2)检验进行统计学分析。结果159例HLD患者中肝病组142例(其中严重肝病组34例,普通肝病组108例),脑病组17例,肝病组和脑病组发病的中位数年龄差异有统计学意义[12.6(7.0,13.3)岁对16.9(11.0,21.5)岁,P<0.01]。83例有基因检测结果的患者累计发现156个ATP7B基因突变位点,其中54例携带p.Arg778Leu基因突变(等位基因频率46.2%)。与其他类型基因突变患者(n=65)相比,p.Arg778Leu纯合突变患者(n=18)血液铜蓝蛋白和白蛋白水平更低,预后指数和Child-Pugh评分、国际标准化比值更高,凝血酶原时间更长(P值均<0.05)。严重肝病组溶血性贫血、角膜K-F环、p.Arg778Leu纯合突变、以及多项实验室指标与普通肝病组相比差异有统计学意义(P值均<0.05)。多因素logistic回归分析显示严重肝病的预测因素为p.Arg778Leu纯合突变、总胆红素、胆汁酸(OR分别为16.512、1.022、1.021,95%CI分别为1.204~226.425、1.005~1.039、1.006~1.037,P值均<0.05),绘制受试者操作特征曲线的界值为0.2153,曲线下面积为0.9532,灵敏度为90.91%,特异度为92.42%。结论HLD患者肝病表型常见且起病早,总胆红素、胆汁酸、ATP7B基因的p.Arg778Leu纯合突变与HLD患者肝病严重程度相关,有助于预测严重肝病发生风险。

ObjectiveTo investigate the clinical and genetic characteristics and predictive role of the severe liver disease phenotype in patients with hepatolenticular degeneration(HLD).MethodsInpatients with HLD confirmed at Xinhua Hospital affiliated with Shanghai Jiao Tong University School of Medicine from January 1989 to December 2022 were selected as the research subjects.Clinical classification was performed according to the affected organs.Patients with liver disease phenotypes were classified into the liver disease group and further divided into the severe liver disease group and the ordinary liver disease group.The clinical characteristics and genetic variations were compared in each group of patients.The predictive indicators of patients with severe liver disease were analyzed by multiple regression.Statistical analysis was performed using the t-test,Mann-Whitney U test,orχ^(2) test according to different data.ResultsOf the 159 HLD cases,142 were in the liver disease group(34 in the severe liver disease group and 108 in the ordinary liver disease group),and 17 were in the encephalopathy group.The median age of onset was statistically significantly different between the liver disease group and the encephalopathy group[12.6(7.0,13.3)years versus 16.9(11.0,21.5)years,P<0.01].156 ATP7B gene mutation sites were found in 83 cases with genetic testing results,of which 54 cases carried the p.Arg778Leu gene mutation(allele frequency 46.2%).Compared with patients with other types of gene mutations(n=65),patients with homozygous p.Arg778Leu mutations(n=18)had lower blood ceruloplasmin and albumin levels,a higher prognostic index,Child-Pugh score,an international normalized ratio,and prothrombin time(P<0.05).Hemolytic anemia,corneal K-F ring,homozygous p.Arg778Leu mutation,and multiple laboratory indexes in the severe liver disease group were statistically significantly different from those in the ordinary liver disease group(P<0.05).Multivariate logistic regression analysis showed that the predictive factors for severe liver disease were homozygous p.Arg778Leu mutation,total bilirubin,and bile acids(ORs=16.512,1.022,1.021,95%CI:1.204-226.425,1.005-1.039,and 1.006-1.037,respectively,P<0.05).The drawn ROC curve demonstrated a cutoff value of 0.2153,an AUC of 0.9532,and sensitivity and specificity of 90.91%and 92.42%,respectively.ConclusionLiver disease phenotypes are common in HLD patients and have an early onset.Total bilirubin,bile acids,and the homozygous p.Arg778Leu mutation of ATP7B is related to the severity of liver disease in HLD patients,which aids in predicting the occurrence and risk of severe liver disease.