慢性肝病肠道微生态改变及其对肝癌的诊断作用研究

发布时间：2018-05-06 06:36

本文选题：肝癌 + 肝硬化　；参考：《浙江大学》2017年硕士论文

【摘要】：目的比较分析肝硬化、肝癌和自身免疫性肝病患者的肠道优势菌群特点及其与临床指标的相关性,筛选能够早期诊断肝癌的特异性微生态指标。方法收集2014年1月至2017年2月间在浙江大学医学院附属第一医院及杭州树兰医院就诊并入组的患者共117例和健康对照30例。根据临床诊断,将病例组分为肝硬化(包括乙肝肝硬化和酒精性肝硬化)、肝癌和自身免疫性肝病(包括原发性胆汁性肝硬变与自身免疫性肝炎)三组,分析三组患者的临床表现、实验室指标、Child-Pugh评分、MELD评分、肠道优势菌群的特点和差异性及其与临床指标的相关性;运用单因素方差分析比较病例组之间及其与健康对照组之间的肠道优势菌群差异性,采用Pearson相关性分析,利用Logistic回归进行单因素分析,筛选出肝癌的特异性肠道细菌,建立指标模型;并将指标模型进行ROC曲线拟合检验,计算其敏感性和特异性。结果本研究中共纳入117例慢性肝病患者,以中老年人群为主,平均年龄55.4±12岁,男/女=1.39:1。肝硬化及肝癌患者以男性为主,所占比例分别为79.5%与81.6%,自身免疫性肝病患者则以女性为主(94.3%)。肝癌与肝硬化患者的Child-Pugh评分及MELD评分均存在极显著性差异(P0.001)。肝癌及肝硬化患者多以全身症状及消化道不适为主要临床表现,且50%以上患者有门脉高压症表现。总体上,肝硬化组并发症发生率总体高于肝癌组。肝癌、肝硬化、自身免疫性肝病及健康对照四组组间对比结果提示普拉梭菌、肠球菌、类杆菌、双歧杆菌、乳酸菌、柔嫩梭菌、直肠真杆菌、肠杆菌及B/E值均存在极显著性差异(P0.01)。与健康对照组相比,三个病例组有益细菌双歧杆菌以及B/E值均显著降低,有害菌肠杆菌均显著增加;肝硬化患者肠道柔嫩梭菌显著减少。与其他三组相比,自身免疫性肝病组肠球菌含量显著减少而类杆菌显著增多。相对于其他三组,肝癌患者肠道中具有抗炎作用及产丁酸作用的普拉梭菌相对较少而直肠真杆菌较多。肠道菌群与实验室指标相关性分析结果显示:肝癌组中,普拉梭菌与中性粒细胞百分比(NEUT%)及纤维蛋白原(FBG),直肠真杆菌与NEUT%、超敏C反应蛋白(CRP)、FBG、凝血酶原时间(PT)及Child-Pugh和MELD评分,肠球菌与血小板(PLT),类杆菌与FBG,均呈负相关,而直肠真杆菌与ALB呈正相关,且该组中的相关性均为中度相关。肝硬化组中,普拉梭菌和直肠真杆菌均与谷丙转氨酶(ALT)及谷草转氨酶(AST)呈正相关,而与CRP呈负相关,类杆菌和柔嫩梭菌与白细胞计数(WBC)、中性粒细胞绝对值(NEUT#)、CRP,类杆菌与Child-Pugh评分,酪酸梭菌与CRP,均呈负相关,而肠球菌与CRP呈正相关。利用Logistic回归进行单因素分析筛选出肝癌特异性微生态指标即直肠真杆菌与普拉梭菌的对数值比值(1gEr/1gFp),其与血清甲胎蛋白(AFP)均能区分肝癌与非肝癌患者,但1gEr/1gFp能够鉴别出AFP值在正常范围内的肝癌病例及AFP高于正常值的肝硬化病例(P0.01)。将AFP、1gEr/1gFp进行二元Logistic回归分析显示,1gEr/1gFp(P0.05)对肝癌的诊断价值大于AFP(P≥0.05);将两个指标及两者联合对肝癌的检测进行ROC曲线拟合:对于肝癌与肝硬化,1gEr/1gFp与AFP联合检测的ROC曲线下面积最大(AUC=0.786),对肝癌的诊断效果最好,其次为 1gEr/1gFp(AUC=0.748),均优于 AFP(AUC=0.664);且 1gEr/1gFp 的特异性较高(97.7%)。在肝癌与自身免疫性肝病两组,两者联合检测对肝癌的诊断效果最好(AUC=0.949),且其敏感性与特异性分别为81.6%和100%。对于肝癌与高AFP肝硬化以及低AFP肝癌与肝硬化,1gEr/1gFp的ROC曲线下面积均大于0.8,对肝癌的诊断具有一定的的准确性,且1gEr/1gFp对于区分肝癌与高AFP肝硬化的特异性较高为93.3%,而区分低AFP肝癌与肝硬化的敏感性较好为76.5%。对于肝癌与非肝癌患者,1gEr/1gFp与AFP联合检测对肝癌的诊断效果最好(AUC=0.804),其次为 1gEr/1gFp(AUC=0.752),1gEr/1gFp 及联合检测对肝癌诊断的特异性高达98.4%。结论肝癌、肝硬化及自身免疫性肝病患者的肠道优势菌群结构发生了显著的变化,有益细菌双歧杆菌显著减少,有害菌肠杆菌显著增加。在肝硬化发展到肝癌的过程中,肠道菌群可能发生了一些特异性的改变。肝癌患者肠道中同样具有抗炎作用及产丁酸作用的普拉梭菌相对较低,而直肠真杆菌相对较高。肝癌及肝硬化患者肠道菌群与炎症指标、肝功能及凝血功能相关性较高。肠道微生态指标1gEr/1gFp对肝癌诊断的价值大于血清AFP指标;1gEr/1gFp能够很好地区分出AFP值在正常范围内的肝癌患者以及AFP高于正常值的肝硬化患者;总体上,1gEr/1gFp及联合检测对肝癌诊断的特异性优于AFP,且1gEr/1gFp与AFP联合检测对肝癌的诊断效果最好。
[Abstract]:Objective to compare and analyze the characteristics of intestinal predominant flora in patients with liver cirrhosis, liver cancer and autoimmune liver disease, and to select the specific microecological indicators for early diagnosis of liver cancer. Methods the methods were collected from January 2014 to February 2017 at the first hospital of Zhejiang University and Hangzhou Shu Lan hospital. A total of 117 patients and 30 healthy controls were divided into three groups: liver cirrhosis (including hepatitis B cirrhosis and alcoholic cirrhosis), liver cancer and autoimmune liver disease (including primary biliary cirrhosis and autoimmune hepatitis), and analyzed the clinical manifestation, laboratory index, Child-Pugh score, MEL of the patients in the three groups. D score, the characteristics and differences of intestinal dominant flora and the correlation with clinical indexes, and using single factor variance analysis to compare the difference of intestinal dominant bacteria groups between the cases and the healthy control groups, using the Pearson correlation analysis, and using the Logistic regression to carry out single factor analysis to screen out the specific intestinal microflora of the liver cancer. The index model was established, and the index model was tested by ROC curve fitting to calculate its sensitivity and specificity. Results 117 cases of chronic liver disease were included in the study. The average age was 55.4 + 12 years old. The male / female =1.39:1. liver cirrhosis and liver cancer patients were mainly male, and the proportion of them was 79.5% and 81.6%, respectively. Patients with immune liver disease were predominantly female (94.3%). There were significant differences in Child-Pugh scores and MELD scores in patients with liver cancer and cirrhosis (P0.001). The main clinical manifestations of liver cancer and liver cirrhosis were systemic symptoms and digestive discomfort, and more than 50% of the patients had portal hypertension. The overall rate of birth was higher than that of the liver cancer group. The results of four groups of liver cancer, liver cirrhosis, autoimmune liver disease and health control group showed that there were significant differences in the value of prasulosis, Enterococcus, bacillus, Bifidobacterium, lactic acid bacteria, Clostridium tenoteriae, rectal true bacilli, Enterobacteriaceae and B/E (P0.01). Compared with the healthy control group, the three case groups were more beneficial than those in the healthy control group. The value of Bifidobacterium and B/E decreased significantly, and the Enterobacter Clostridium in the intestinal tract of the patients with liver cirrhosis significantly decreased. Compared with the other three groups, the content of Enterococcus in the autoimmune liver disease group was significantly reduced and the bacilli increased significantly. Compared with the other three groups, the intestinal cancer patients have the anti inflammatory effect and the production of butyric acid. The results of correlation analysis between intestinal flora and laboratory indicators showed that the percentage of prasperic and neutrophils (NEUT%) and fibrinogen (FBG), protobacter and NEUT%, hypersensitive C reactive protein (CRP), FBG, prothrombin time (PT), Child-Pugh and MELD scores in the liver cancer group were found in the liver cancer group. Enterococcus and platelets (PLT), bacilli and FBG were negatively correlated, while true rectal bacillus was positively correlated with ALB, and the correlation in this group was moderately related. In the liver cirrhosis group, pralopilia and true rectal Bacillus were positively correlated with alanine aminotransferase (ALT) and cereal transaminase (AST), but negatively related to CRP, Bacillus subtilis and Clostridium tenotuum and white Cell count (WBC), absolute neutrophils (NEUT#), CRP, bacilli and Child-Pugh scores, Clostridium butyricum and CRP were negatively correlated, and Enterococcus was positively correlated with CRP. The specific microecological index of liver cancer, namely, the specific ratio of Enterococcus enteriformis and praticelline (1gEr/1gFp), was screened by Logistic regression. Serum alpha fetoprotein (AFP) can distinguish between liver cancer and non liver cancer patients, but 1gEr/1gFp can identify AFP value in normal range of liver cancer cases and AFP higher than normal value of liver cirrhosis (P0.01). AFP, 1gEr/1gFp two yuan Logistic regression analysis showed that 1gEr/1gFp (P0.05) for the diagnosis of liver cancer is greater than AFP (P > 0.05); two will be ROC curve fitting for the detection of liver cancer by combination of indexes and both: for liver cancer and liver cirrhosis, the area of ROC curve under the combination of 1gEr/1gFp and AFP was the largest (AUC=0.786), which was best for the diagnosis of liver cancer, followed by 1gEr/1gFp (AUC=0.748), which was superior to AFP (AUC=0.664), and the specificity of 1gEr/1gFp was higher (97.7%). In liver cancer and itself In the two groups of immune liver diseases, the combined detection of liver cancer was the best (AUC=0.949), and its sensitivity and specificity were 81.6% and 100%. for liver cancer and high AFP liver cirrhosis and low AFP liver cancer and liver cirrhosis. The area of ROC curve under 1gEr/1gFp was more than 0.8, and the diagnosis of liver cancer was accurate and 1gEr/1gFp for the diagnosis of liver cancer. The specificity of distinguishing liver cancer from high AFP liver cirrhosis is 93.3%, and the sensitivity of differentiating the low AFP liver cancer and liver cirrhosis is better than that of 76.5%. for the patients with liver cancer and non liver cancer. The combination of 1gEr/1gFp and AFP for the diagnosis of liver cancer is best (AUC=0.804), followed by 1gEr/1gFp (AUC= 0.752), 1gEr/1gFp and the specificity of the combined detection of the diagnosis of liver cancer. The intestinal flora structure of the patients with liver cancer, liver cirrhosis and autoimmune liver disease was significantly changed, the beneficial bacterial Bifidobacterium decreased significantly and the Enterobacteriaceae increased significantly. During the development of liver cirrhosis to liver cancer, the intestinal microflora may have some specific changes. The intestinal tract of the liver cancer patients was 98.4%.. The bacteria of pralopulac is relatively low in anti-inflammatory and butyric acid production, while the true rectal bacillus is relatively high. The intestinal microflora of the patients with liver cancer and liver cirrhosis has a higher correlation with the inflammatory markers, liver function and blood coagulation function. The value of the intestinal microecological index 1gEr/1gFp is greater than the serum AFP index; 1gEr/1gFp can be a good area. The AFP value in the normal range of liver cancer patients and the patients with AFP higher than the normal value of liver cirrhosis; in general, the specificity of 1gEr/1gFp and combined detection on the diagnosis of liver cancer is superior to AFP, and the combined detection of 1gEr/1gFp and AFP is the best for the diagnosis of liver cancer.

【学位授予单位】：浙江大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R575;R735.7

【参考文献】