仝 靜, 孫長(zhǎng)宇, 楊黎冰, 梁亞林, 康艷楠
(鄭州大學(xué)第一附屬醫(yī)院 感染科,鄭州 450052)
論著/肝纖維化及肝硬化
胸腺肽α1對(duì)乙型肝炎肝硬化失代償期患者淋巴細(xì)胞亞群的影響
仝 靜, 孫長(zhǎng)宇, 楊黎冰, 梁亞林, 康艷楠
(鄭州大學(xué)第一附屬醫(yī)院 感染科,鄭州 450052)
目的觀察乙型肝炎肝硬化失代償期患者應(yīng)用胸腺肽α1后外周血淋巴細(xì)胞亞群的變化,分析胸腺肽α1對(duì)患者免疫功能的影響。方法選取2015年10月-2016年12月鄭州大學(xué)第一附屬醫(yī)院收治的乙型肝炎肝硬化失代償期患者106例,隨機(jī)分為對(duì)照組和治療組各53例,另選同期20例體檢者作為健康組。對(duì)照組給予內(nèi)科綜合治療,治療組在綜合治療的基礎(chǔ)上加用胸腺肽α1,分別于治療前、治療12周后使用流式細(xì)胞儀器檢測(cè)患者外周血CD3+、CD4+、CD8+細(xì)胞數(shù)、CD4+/CD8+比值、CD19百分比、NK細(xì)胞百分比。觀察臨床癥狀和并發(fā)癥,以及不良反應(yīng)發(fā)生情況。計(jì)量資料多組間比較采用方差分析,進(jìn)一步兩兩比較采用LSD-t檢驗(yàn);兩組間比較采用成組t檢驗(yàn)或配對(duì)t檢驗(yàn)。計(jì)數(shù)資料的組間比較采用χ2檢驗(yàn)。結(jié)果治療前,與健康組相比,治療組和對(duì)照組患者外周血CD3+、CD4+、CD8+細(xì)胞數(shù)、CD4+/CD8+比值、CD19百分比、NK細(xì)胞百分比均明顯降低(P值均<0.05);治療12周后,與對(duì)照組相比,治療組CD3+、CD4+、CD8+細(xì)胞數(shù)明顯升高(t值分別為5.051、5.379、2.066,P值均<0.05),CD4+/CD8+比值、CD19細(xì)胞百分比、NK細(xì)胞百分比有升高趨勢(shì)(P值均>0.05)。治療組治療12周與治療前相比,CD3+細(xì)胞數(shù)、CD4+細(xì)胞數(shù)、CD4+/CD8+比值明顯升高(t值分別為7.647、7.851、4.384,P值均<0.001)。治療過程中,出現(xiàn)的不良反應(yīng)為頭暈、頭痛,對(duì)照組和治療組患者不良反應(yīng)發(fā)生率比較,差異無統(tǒng)計(jì)學(xué)意義(χ2=1.039,Ρ=0.308)。所有病例未發(fā)生嚴(yán)重不良反應(yīng)。結(jié)論胸腺肽α1可明顯改善乙型肝炎肝硬化失代償患者淋巴細(xì)胞亞群比例失衡問題,提高患者免疫功能。
肝硬化; 肝炎, 乙型; 淋巴細(xì)胞亞群; 胸腺素
據(jù)2006年全國(guó)乙型肝炎流行病學(xué)調(diào)查顯示,我國(guó)HBV感染人數(shù)約9300萬人,其中約1/4將發(fā)展為慢性肝病,部分可發(fā)展為肝硬化。代償期肝硬化進(jìn)展為肝功能失代償?shù)哪臧l(fā)生率為3%~5%,失代償期肝硬化5年生存率為14%~35%[1]。失代償期肝硬化患者多存在免疫功能低下,淋巴細(xì)胞亞群失調(diào)[2-3],容易出現(xiàn)嚴(yán)重感染、腫瘤等。而胸腺肽α1作為免疫調(diào)節(jié)劑已廣泛用于多種疾病的治療,如重癥感染、變態(tài)反應(yīng)、神經(jīng)內(nèi)分泌疾病、各類腫瘤治療及化療后的免疫功能恢復(fù)等[4-5]。目前胸腺肽α1對(duì)治療乙型肝炎肝硬化失代償期患者免疫功能低下的療效尚缺乏臨床研究。本研究采用前瞻性分析,在乙型肝炎肝硬化失代償期患者綜合治療基礎(chǔ)上加用胸腺肽α1,并在治療12周后復(fù)查相關(guān)指標(biāo),分析胸腺肽α1對(duì)于乙型肝炎肝硬化失代償期患者淋巴細(xì)胞亞群的影響,進(jìn)而了解患者免疫功能的變化。
1.1 研究對(duì)象 選取2015年10月-2016年12月本院收治的乙型肝炎肝硬化失代償期患者,診斷均符合《慢性乙型肝炎防治指南(2015年更新版)》[1]中乙型肝炎肝硬化失代償期診斷標(biāo)準(zhǔn),通過病史及檢查排除其他病因?qū)е碌母斡不Т鷥?,如HCV感染、自身免疫性肝炎、酒精、藥物等,同時(shí)排除各種腫瘤、血液病及風(fēng)濕免疫系統(tǒng)疾病、腦血管病急性期及嚴(yán)重肝腎功能障礙和合并各種感染的患者。采用隨機(jī)數(shù)字表分法分為治療組和對(duì)照組。同時(shí)選擇本院門診健康體檢者做為健康組。本研究經(jīng)本院倫理委員會(huì)批準(zhǔn),所有治療均獲得患者及家屬知情同意。
1.2 治療方法 兩組給予相同藥物進(jìn)行抗病毒、保護(hù)胃黏膜、護(hù)肝、補(bǔ)充人血白蛋白、引流腹水、維持水電解質(zhì)平衡、調(diào)節(jié)腸道菌群、預(yù)防抗感染等內(nèi)科綜合治療;治療組在綜合治療的基礎(chǔ)上加用1.6 mg 胸腺肽α1(和日,海南中和藥業(yè)有限公司)皮下注射,2次/周,每次使用間隔3~4 d,治療12周。
1.3 觀察指標(biāo) 應(yīng)用本院感染科實(shí)驗(yàn)室流式細(xì)胞儀(FACS Calibur流式細(xì)胞儀,美國(guó)BD公司)監(jiān)測(cè)所有患者治療前、治療12周外周血淋巴細(xì)胞亞群,觀察患者外周血CD3+、CD4+、CD8+細(xì)胞數(shù)、CD4+/CD8+比值、CD19百分比、自然殺傷細(xì)胞(NK細(xì)胞)百分比變化,同時(shí)監(jiān)測(cè)所有患者的不良反應(yīng)。
2.1 一般資料 共收集乙型肝炎肝硬化失代償期患者106例,其中男89例,女17例;年齡27~83歲,平均(53.2±11.1)歲。治療組和對(duì)照組各53例。治療前,2組患者在性別,年齡,CD3+、CD4+、CD8+T淋巴細(xì)胞數(shù),CD4+/CD8+比值,CD19百分比,NK細(xì)胞百分比之間差異均無統(tǒng)計(jì)學(xué)意義(P值均>0.05),具有可比性。健康組20例,其中男13例,女7例,年齡35~79歲,平均(58.0±12.9)歲,健康組與對(duì)照組、治療組相比,性別、年齡差異均無統(tǒng)計(jì)學(xué)意義(P值均>0.05)。
2.2 3組治療前、治療12周外周血淋巴細(xì)胞亞群變化情況 治療前,3組間各指標(biāo)比較差異均有統(tǒng)計(jì)學(xué)意義(P值均<0.05),進(jìn)一步兩兩間比較顯示,健康組患者外周血CD3+、CD4+、CD8+細(xì)胞數(shù),CD4+/CD8+比值,CD19百分比,NK細(xì)胞百分比明顯高于對(duì)照組和治療組(P值均<0.05),治療組和對(duì)照組兩組間各指標(biāo)比較,差異均無統(tǒng)計(jì)學(xué)意義(P值均>0.05)。
治療12周后,與對(duì)照組相比,治療組CD3+、CD4+、CD8+細(xì)胞數(shù)明顯升高(P值均<0.05),CD4+/CD8+比值、CD19細(xì)胞百分比、NK細(xì)胞百分比有升高趨勢(shì)(P值均>0.05)。
治療組治療12周與治療前相比,CD3+細(xì)胞數(shù)、CD4+細(xì)胞數(shù)、CD4+/CD8+比值明顯升高(t值分別為7.647、7.851、4.384,P值均<0.001),CD8+細(xì)胞數(shù)、CD19細(xì)胞百分比、NK細(xì)胞百分比有升高趨勢(shì)(P值均>0.05)(表1)。
2.3 臨床癥狀及并發(fā)癥發(fā)生情況 106例患者治療12周后,治療組53例患者中49例乏力納差等癥狀明顯好轉(zhuǎn),出現(xiàn)感染3例;對(duì)照組53例患者中31例乏力納差等癥狀減輕,出現(xiàn)感染16例,給予抗感染治療后感染均得到控制。治療期間2組患者均未出現(xiàn)出血及危及生命的并發(fā)癥。
2.4 不良反應(yīng)發(fā)生情況 106例患者治療過程中,治療組出現(xiàn)1例頭暈;對(duì)照組出現(xiàn)2例頭暈,1例頭痛。2組患者不良反應(yīng)發(fā)生率比較,差異無統(tǒng)計(jì)學(xué)意義(χ2=1.039,P=0.308)。所有病例未發(fā)生嚴(yán)重不良反應(yīng)。
乙型肝炎肝硬化患者由于HBV感染,機(jī)體的細(xì)胞免疫和體液免疫均降低,其中T淋巴細(xì)胞功能降低為免疫衰老的重要特征。而免疫調(diào)節(jié)治療可通過促進(jìn)淋巴細(xì)胞增殖,調(diào)整淋巴細(xì)胞亞群比例,提高患者免疫功能。本研究通過研究患者應(yīng)用免疫調(diào)節(jié)劑(胸腺肽α1)前后淋巴細(xì)胞亞群的變化,為乙型肝炎肝硬化患者提供治療建議,提高患者免疫功能,降低感染率,利于患者病情恢復(fù)。
外周血淋巴細(xì)胞亞群可直接反應(yīng)出機(jī)體免疫功能狀況,人外周血T淋巴細(xì)胞可分為3種不同亞群, 實(shí)驗(yàn)室通常檢查CD3+、CD4+、CD8+T淋巴細(xì)胞亞群。其中CD3+T淋巴細(xì)胞反映外周血T淋巴細(xì)胞總數(shù),CD4+T淋巴細(xì)胞為輔助性T淋巴細(xì)胞,可促進(jìn)B淋巴細(xì)胞、細(xì)胞毒性T淋巴細(xì)胞和其他免疫細(xì)胞的增殖及分化,調(diào)節(jié)體液和細(xì)胞免疫。CD8+T淋巴細(xì)胞由細(xì)胞毒性T淋巴細(xì)胞和抑制性T淋巴細(xì)胞組成,CD8+T淋巴細(xì)胞是決定HBV清除狀態(tài)的關(guān)鍵細(xì)胞亞群,細(xì)胞溶解或非溶解機(jī)制是CD8+T淋巴細(xì)胞清除機(jī)體感染HBV的主要方式。CD4+/CD8+比值的變化可直接反應(yīng)機(jī)體的細(xì)胞免疫功能狀態(tài),正常情況下,在不同機(jī)體內(nèi)CD4+/CD8+比值不同,但在正常范圍內(nèi)。B淋巴細(xì)胞經(jīng)過抗原刺激產(chǎn)生抗體,在體液免疫中發(fā)揮重要作用,可以清除病毒抗原,在長(zhǎng)期病毒抗原刺激下,機(jī)體的體液免疫相對(duì)于細(xì)胞免疫占主導(dǎo)地位。NK細(xì)胞是重要的天然免疫細(xì)胞,可通過殺傷和分泌細(xì)胞因子的方式對(duì)腫瘤細(xì)胞及病毒感染的細(xì)胞產(chǎn)生快速應(yīng)答[6]。
胸腺肽α1是由28個(gè)氨基酸組成的多肽,其在免疫調(diào)節(jié)方面具有重要作用,已被廣泛應(yīng)用于臨床,在疾病治療過程中幫助患者恢復(fù)免疫功能[7-8]。在誘導(dǎo)和促進(jìn)胸腺細(xì)胞的分化和成熟方面,胸腺肽α1可促進(jìn)胸腺內(nèi)的骨髓干細(xì)胞轉(zhuǎn)化為T淋巴細(xì)胞,并進(jìn)一步分化為不同功能亞群,這是其最基本的調(diào)節(jié)作用。另外胸腺肽α1還可刺激干細(xì)胞增殖并增加NK細(xì)胞、CD4+、CD8+T淋巴細(xì)胞的產(chǎn)生,同時(shí)還增加IFN、IL-2等多種活性物質(zhì),刺激并促進(jìn)T淋巴細(xì)胞分化、成熟,使紊亂的免疫功能逐漸恢復(fù),發(fā)揮免疫保護(hù)作用[9-11]。本研究2組患者治療前外周血CD3+、CD4+、CD8+細(xì)胞數(shù)、CD4+/CD8+比值、CD19百分比、NK細(xì)胞百分比明顯降低。在使用胸腺肽α1治療后,與對(duì)照組相比,治療組淋巴細(xì)胞亞群中CD3+、CD4+、CD8+T淋巴細(xì)胞數(shù)升高較為明顯,CD4+/CD8+比值、CD19細(xì)胞百分比、NK細(xì)胞有所升高,表明胸腺肽α1可有效改善乙型肝炎肝硬化失代償期患者的免疫功能。
表1 3組治療前和治療12周外周血淋巴細(xì)胞亞群變化情況比較
注:1)與健康組比較,P<0.05;2)與治療前治療組比較,P<0.05
總之,乙型肝炎肝硬化失代償期患者易出現(xiàn)外周血淋巴細(xì)胞亞群失衡,治療過程中加用胸腺肽α1可明顯改善T淋巴細(xì)胞亞群比例失衡問題,提高患者免疫功能,利于患者病情恢復(fù)。但本研究樣本量較少,研究時(shí)間短,資料收集不完整(比如失代償期分級(jí)未進(jìn)一步研究等),分析過程中難免有誤差,胸腺肽α1對(duì)改善乙型肝炎肝硬化失代償期患者免疫功能的長(zhǎng)期療效還有待進(jìn)一步研究。
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引證本文:TONG J, SUN CY, YANG LB, et al. Effect of thymosin α1 on lymphocyte subsets in patients with decompensated hepatitis B cirrhosis[J]. J Clin Hepatol, 2017, 33(11): 2132-2135. (in Chinese)
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(本文編輯:朱 晶)
Effectofthymosinα1onlymphocytesubsetsinpatientswithdecompensatedhepatitisBcirrhosis
TONGJing,SUNChangyu,YANGLibing,etal.
(DepartmentofInfectiousDiseases,TheFirstAffiliatedHospitalofZhengzhouUniversity,Zhengzhou450052,China)
ObjectiveTo investigate the change in peripheral blood lymphocyte subsets after the application of thymosin α1 in patients with decompensated hepatitis B cirrhosis, as well as the effect of thymosin α1 on immune function.MethodsA total of 106 patients with decompensated hepatitis B cirrhosis who were admitted to The First Affiliated Hospital of Zhengzhou University from October 2015 to December 2016 were enrolled and randomly divided into control group and treatment group, with 53 patients in each group, and 20 healthy subjects who underwent physical examination were enrolled as healthy group. The patients in the control group were given comprehensive medical treatment, and those in the treatment group were given thymosin α1 in addition to the comprehensive medical treatment. Flow cytometry was used to measure peripheral blood CD3+, CD4+, and CD8+cells, CD4+/CD8+ratio, and percentages of CD19 cells and natural killer (NK) cells before treatment and after 12 weeks of treatment. Clinical symptoms, complications, and adverse events were observed. An analysis of variance was used for comparison of continuous data between multiple groups, and the least significant differencet-test was used for further comparison between any two groups; the independent-samplesttest or pairedt-test was used for comparison between two groups. The chi-square test was used for comparison of categorical data between groups.ResultsBefore treatment, the treatment group and the control group had significantly lower numbers of peripheral blood CD3+, CD4+, and CD8+cells, CD4+/CD8+ratio, and percentages of CD19 cells and NK cells than the healthy group (allP<0.05). After 12 weeks of treatment, the treatment group showed significant increases in the numbers of CD3+and CD4+cells and CD4+/CD8+ratio(t=7.647,7.851, and 4.384, allP<0.001); compared with the control group, the treatment group had significantly increased numbers of CD3+, CD4+, and CD8+cells (t=5.051, 5.379, and 2.066, allP<0.05) and slightly increaseed CD4+/CD8+ratio and percentages of CD19 cells and NK cells (allP>0.05). The adverse events during treatment included dizziness and headache, and there was no significant difference in the incidence rate of adverse events between the control group and the treatment group (χ2=1.039,P=0.308). No patient experienced serious adverse events.ConclusionIn patients with decompensated hepatitis B cirrhosis, thymosin α1 can significantly improve the imbalance of lymphocyte subsets and enhance their immune function.
liver cirrhosis; hepatitis B; lymphocyte subsets; thymosin
R512.62; R575.2
A
1001-5256(2017)11-2132-04
10.3969/j.issn.1001-5256.2017.11.016
2017-05-17;
2017-07-03。
河南省醫(yī)學(xué)科技攻關(guān)計(jì)劃項(xiàng)目(152102310045)
仝靜(1991-),女,主要從事肝病及感染性發(fā)熱疾病的研究。
孫長(zhǎng)宇,電子信箱: changyu8188@163.com。