CK18在慢性乙型肝炎后肝硬化、肝癌和手术相关肝损伤中的作用

发布时间：2018-06-19 03:36

本文选题：CK18 + 慢性乙型肝炎　；参考：《北京协和医学院》2014年博士论文

【摘要】：研究背景慢性乙型肝炎是长期以来威胁中国人民生命健康的一个重要的因素。反复的炎症刺激引起肝纤维化,进而出现不可逆转的肝硬化,在此基础上导致肝细胞肝癌的发生。中国的慢性乙型肝炎病毒携带者数量在一亿左右,每年每十万患者中因慢性肝炎肝硬化死亡者为24.5,因肝细胞肝癌死亡者为14.5。近年来,随着预防接种的普及,乙型肝炎病毒的感染率有了明显的下降,但仍处在相当高的水平,在某些地区尤其居高不下。由于慢性乙型肝炎后肝硬化与肝癌的发生与进展都很隐蔽,在确诊时往往已经难以挽回,导致肝硬化与肝癌的预后不良。因此,对慢性乙型肝炎后肝硬化、肝癌的早期诊断十分重要。目前对慢性乙型肝炎后肝癌的早期诊断主要依靠血清AFP和肝脏超声检查的联合应用,取得了良好的效果。对更新更好的HCC血清标记物的探索仍在继续,其中GP-73、GPC-3、AFP-L3展现出了较大的潜力。然而,对于慢性乙型肝炎后肝硬化的早期诊断仍然是一个棘手的问题。现有的针对肝纤维化与肝硬化病理生理过程的机制研究发现了一些有希望的血清标记物,如PⅢNP、HA、LN等。但实际应用研究发现即使是这些标记物中诊断效能最好的几种,也不是临床上理想的选择。目前对慢性乙型肝炎后肝纤维化与肝硬化的诊断金标准仍然是肝组织活检。但由于肝组织活检是有创检查,不能广泛应用,患者在接受肝穿刺活检时难免存在顾虑；而且难以反复取材监测病情的动态变化,不能预测病情的发展。因此,研发一种新的诊断肝纤维化程度的血清学指标成为目前迫切的需求。 CK18属于细胞角蛋白家族,是正常细胞骨架的构成成分,在多种上皮细胞中均有表达。CK18与慢性乙型肝炎后肝硬化以及肝癌的关系已经得到了初步的关注,但CK18在这一病理生理过程中的具体意义以及和CK18对肝纤维化、肝硬化的诊断价值尚无系统研究报道。其次,由于CK18属于细胞骨架成分,在肝细胞被破坏时能够释放到血液中,因而从机制上分析,肝脏肿瘤患者和手术相关的肝损伤也可能引起血清CK18水平的变化。研究CK18在肝癌中的表达对于肝癌诊断、复发和预后观察可能有潜在的意义；同样,术前术后CK18水平的动态变化可能反映手术损伤,从而帮助判断损伤程度和术后恢复进程。以上两方面研究内容目前尚属空白,在国际上还没有相应的文献报道,其结果将有明显的研究意义和临床价值。研究目的 (1)基于CK18在肝纤维化、肝硬化和肝癌中可能起到的作用,本研究首先应明确血清CK18在慢性乙型肝炎后肝硬化合并肝癌的患者中是否较正常人群有所变化； (2)由于国内大多数慢性乙型肝炎患者都存在程度不一的肝纤维化和肝硬化,本研究致力于阐明引起性乙型肝炎后肝硬化合并肝癌的患者血清CK18变化的主要原因是肝硬化还是肝癌,哪个因素是主要的,或两者共同对于CK18血清学变化起到作用； (3)CK18属于细胞骨架成分,在肝细胞破坏时能够释放入血,因此有理由认为手术相关的肝细胞损伤能够影响血清CK18的水平。本研究试图探索CK18与手术相关肝损伤的关系,CK18水平能否反映肝脏损伤的程度以及术后康复的程度。 (4)手术相关肝损伤属于急性肝损伤,而急性和慢性肝损伤的机制存在差别。本研究对比手术造成的急性肝损伤与肝纤维化、肝硬化及肝癌造成的慢性肝损伤,这两种类型的肝损伤对血清CK18水平变化的影响的程度,以探究其机制上的差别,以及这种差别能否帮助临床上治疗肝硬化、肝癌的患者的过程中其疾病的进程和预后的判断。实验方法 2013年12月至2014年6月间,在北京协和医院肝脏外科病房的手术病人中选取慢性乙型肝炎后肝硬化合并肝癌的患者作为研究组,肝海绵状血管瘤患者作为对照组,其中慢性乙型肝炎后肝硬化合并肝癌的患者在4周内未接受抗肿瘤治疗。临床信息包括患者年龄、性别、肝功能Child-Pugh评分、血清AFP、肿瘤大小、巴塞罗那分期。两组患者分别在术前、术后第一天、术后第三天、术后第五天采集外周静脉血,用M65和M30ELISA法分别测定其总CK18与CK18裂解片段的浓度。结果慢性乙型肝炎后肝硬化合并肝癌的患者术前的血清总CK18与CK18裂解片段水平均明显高于对照组(总CK18:262.9±130.0U/L,对照组158.7±44.5U／L,P=0.038；CK18片段：145.1±69.6U／L,对照组81-6±15.2U／L,P=0.005),提示慢性乙型肝炎后肝硬化合并肝癌的患者的血清CK18水平确实较正常人群有明显升高。在术后第五天,慢性乙型肝炎后肝硬化合并肝癌的患者的血清总CK18与CK18裂解片段水平均降至接近正常值(总CK18：311.9±158.8U／L,对照组180.8±54.1U/L, P=0.078; CK18片段：103.5±32.0U／L,对照组82.9±8.0U／L,P=0.012),但由于样本数量的限制,难以判断肝硬化与肝癌对血清CK18的升高的影响的具体程度与相互关系。 CKl8在术前术后的动态变化呈现出与ALT类似的趋势,在术后第一天达到峰值,然后开始逐渐下降,在术后第五天达到与术前相当的水平。其中肝细胞坏死产生的CK18与ALT有明显的相关性(肝癌组相关系数为0.659,对照组为0.922)。而ALT在术后第五天时仍处在高于术前的水平(血管瘤组术前ALT11.±3.0U／L,术后第五天99.0±70.4U／L,P=0.01；肝癌组术前ALT19.8+8.0U／L,术后第五天188.1±119.4U／L,P=0),可能意味着CK18具有比ALT更加敏感、或有更短的半衰期,这个结论尚无文献报道,是首次发现。肝癌组术后第一天的总CK18(术前262.9±130.1U／L,术后第一天1286.9±984.3U／L,P=0.005)与肝细胞坏死产生的CK18(术前117.8±117.2U／L,术后第一天1065.6±831.9U／L,P=0.002)都显著高于术前,而且升高的幅度非常大,这说明手术造成的急性肝损伤对血清CK18影响程度要远远大于肝硬化、肝癌造成的慢性肝损伤。结论 (1)血清CK18在慢性乙型肝炎后肝硬化的患者中有明显升高,这与研究设计时的预期结果一致,说明慢性乙型肝炎后肝硬化和肝癌确实能够导致该细胞骨架结构释放入血液；在CK18升高的人群中,慢性乙型肝炎的影响因素也是一个需要考虑的问题,已有的研究已经表明控制良好、无肝炎活动的慢性乙型肝炎病毒感染者,其血清CK18与正常人群相近,因此我们的研究认为慢性乙型肝炎后肝硬化的患者中血清CK18的升高主要与肝脏损害相关,可能可以作为慢性肝脏损害的潜在标志物； (2)在慢性乙型肝炎后肝硬化合并肝癌的患者中,肝癌可能是引起血清CK18升高的因素中更主要的方面,本研究首次发现了这种趋势,如果进一步增加样本数,应该能够得到更有说服力的结果； (3)本研究首次证实了手术损伤能够引起血清CK18升高,这与CK18在肝细胞破坏中的机制是相符合的。此外,本研究还发现,血清CK18在术后第五天能够降至接近术前水平,而ALT在术后第五天仍显著高于术前水平；这提示CK18可能比ALT更加敏感,或者在血中代谢更快。这点尚无文献报道,是首次发现。它的意义可能在于,在体内如果没有持续的肝细胞损伤而产生新的CK18产物,则血清中CK18水平能够很快下降,这对于监测疾病的活动情况、判断用药效果都有很大的帮助。 (4)对比慢性肝损伤,如肝纤维化和肝硬化,和急性肝损伤,如手术创伤,后者的血清CK18水平变化更大,可能暗示了在急性肝损伤过程中细胞骨架碎片释放入血液的量更为显著。这个结果对于临床上治疗肝硬化、肝癌的患者过程中对疾病的进程和预后的判断可能有重大意义。
[Abstract]:Background of the study

Chronic hepatitis B is an important factor which has long threatened the health of Chinese people . Repeated inflammatory stimulation causes liver fibrosis , which leads to the occurrence of liver cancer . In recent years , with the popularization of hepatitis B virus , the infection rate of hepatitis B virus has decreased significantly .

At present , the early diagnosis of liver cancer after chronic hepatitis B mainly depends on the combination of serum AFP and liver ultrasonography , and good results are obtained . The exploration of the better HCC serum markers is still continuing , in which GP - 73 , GPC - 3 , AFP - L3 exhibit greater potential .

However , the early diagnosis of liver cirrhosis after chronic hepatitis B is still a difficult problem . There are some promising serum markers , such as P鈪P , HA , LN , etc .
Therefore , it is urgent to develop a new serological index for the diagnosis of liver fibrosis .

CK18 belongs to the family of cytokeratins , which is a constitutive component of normal cellular skeleton , and has been expressed in various epithelial cells . The relationship between CK18 and chronic hepatitis B cirrhosis and liver cancer has been paid preliminary attention , but the specific significance of CK18 in this pathological process and the diagnosis value of CK18 in liver fibrosis and liver cirrhosis have not been reported .

Secondly , because CK18 belongs to the cytoskeletal component , it can be released into the blood when the liver cells are damaged . Therefore , it is possible to analyze the expression of CK18 in liver cancer , which may have potential significance for the diagnosis , recurrence and prognosis of liver cancer .
In the same vein , the dynamic changes of CK18 level before operation may reflect surgical injury , so as to help judge the degree of injury and the post - operative recovery process . The research contents of the above two aspects are still blank , and there are no corresponding literature reports in the world , and the results will have obvious research significance and clinical value .

Purpose of study

( 1 ) Based on the possible role of CK18 in liver fibrosis , liver cirrhosis and liver cancer , it should be clear whether serum CK18 changes in patients with liver cirrhosis and liver cancer after chronic hepatitis B .

( 2 ) Since most of the patients with chronic hepatitis B have a different degree of liver fibrosis and cirrhosis , the study is focused on the main reason for the change of serum CK18 in patients with cirrhosis and liver cirrhosis after induced hepatitis B is cirrhosis or liver cancer .

( 3 ) CK18 belongs to cytoskeletal component and can be released into blood when the liver cells are damaged . Therefore , it is reasonable to believe that the liver injury associated with surgery can influence the level of serum CK18 . This study attempts to explore the relationship between CK18 and surgical related hepatic injury , and whether CK18 can reflect the degree of liver injury and the degree of postoperative rehabilitation .

( 4 ) The hepatic injury associated with liver injury is an acute liver injury , and the mechanism of acute and chronic liver injury is different . The study compared the effect of acute liver injury with liver fibrosis , liver cirrhosis and liver cancer .

experimental method

From December 2013 to June 2014 , the patients with liver cirrhosis and liver cancer were selected as the control group . The patients with liver cirrhosis and liver cancer were treated with anti - tumor therapy within 4 weeks . The clinical information included age , sex , Child - A score , serum AFP , tumor size and Barcelona stage . The peripheral venous blood was collected on the first day of operation , the first day of operation , and the fifth day after operation .

Results

The serum total CK18 and CK18 cleavage levels were significantly higher in patients with liver cirrhosis after chronic hepatitis B than in the control group ( total CK18 : 262.9 卤 31.0 U / L , 158.7 卤 44.5U / L in the control group , P = 0.038 ) .
CK18 fragment : 145.1 卤 69.6U / L , control group ( 81 - 6 卤 15.2U / L , P = 0.005 ) , suggesting that serum CK18 levels in patients with liver cirrhosis after chronic hepatitis B were significantly higher than those in the normal population .

The serum total CK18 and CK18 cleavage levels of patients with liver cirrhosis and liver cirrhosis were reduced to near normal ( total CK18 : 31.9 卤 158.8U / L , control group 180.8 卤 54.1U / L , P = 0.078 ; CK18 fragment : 103.5 卤 32.0U / L , control group 82.9 卤 8.0U / L , P = 0.012 ) .

The dynamic changes of CK18 were similar to those of ALT before operation . The peak was reached on the first day of operation , then gradually decreased gradually , and the level of CK18 correlated with ALT was reached on the fifth day after operation . The correlation coefficient between CK18 and ALT in hepatocellular necrosis was 0.659 and 0.922 in the control group . ALT was still higher than preoperative level ( ALT11 . 卤 3.0 U / L before operation ) at the fifth day after operation , and the fifth day after operation was 99.0 卤 70.4 U / L , P = 0.01 ;
ALT19.8 + 8.0U / L , the fifth day after operation ( 188.1 卤 119.4U / L , P = 0 ) , may mean that CK18 is more sensitive to ALT , or has a shorter half - life , which has not been reported in the literature for the first time .

The total CK18 ( 262.9 卤 1.1U / L before operation , 126.9 卤 984.3U / L at the first day of operation ) and CK18 ( 117.8 卤 117.2U / L at the first day of operation ) were significantly higher than those of CK18 ( 117.6 卤 117.2U / L , P = 0.002 ) after operation , which indicated that the effect of acute hepatic injury on serum CK18 was much higher than that in liver cirrhosis and liver cancer .

Conclusion

( 1 ) Serum CK18 was significantly elevated in patients with liver cirrhosis after chronic hepatitis B , which was consistent with the expected results at the time of study design , suggesting that cirrhosis and liver cancer after chronic hepatitis B did lead to release of the cytoskeletal structure into the blood ;
In the patients with elevated CK18 , the factors of chronic hepatitis B are also a need to consider . The existing research has shown that the control of the chronic hepatitis B virus infected with hepatitis B is similar to the normal population , so our study suggests that the elevation of serum CK18 in patients with liver cirrhosis after chronic hepatitis B is mainly related to liver injury , which may be a potential marker for chronic liver injury ;

( 2 ) In the patients with liver cirrhosis and liver cirrhosis after chronic hepatitis B , the liver cancer may be a more important aspect of the factors that cause the increase of serum CK18 . This trend is first found in the study , and if the number of samples is further increased , more convincing results should be obtained ;

( 3 ) For the first time , this study confirmed that surgical injury can cause the increase of serum CK18 , which is in agreement with CK18 ' s mechanism in liver cell destruction . In addition , the study also found that serum CK18 can be reduced to near pre - operative level in the fifth day after surgery , while ALT was still significantly higher in the fifth day after operation than preoperative level ;
This suggests that CK18 may be more sensitive to ALT , or more rapidly metabolized in the blood . This is the first finding . It is likely that the CK18 level in serum can be rapidly decreased if there is no persistent hepatocyte injury in the body , which can help monitor the activity of the disease and determine the effect of medication .

( 4 ) Compared with chronic liver injury , such as liver fibrosis and liver cirrhosis , and acute liver injury , such as surgical trauma , the level of serum CK18 in the latter is more significant , which may suggest that the amount of cellular debris released into the blood is more significant during acute liver injury .
【学位授予单位】：北京协和医学院
【学位级别】：博士
【学位授予年份】：2014
【分类号】：R512.62;R575.2;R735.7

【共引文献】