直接抗病毒药物治疗慢性丙型肝炎患者疗效研究

∗基金项目:四川省科技厅自然科学基础研究一般(面上)项目(编号:2018JM7256)
作者单位:638500四川省广安市四川大学华西广安医院药剂科(李亚玲,蒋亚西);感染病科(杨发成)
第一作者:李亚玲,女,49岁,大学本科,副主任药师㊂E-mail: lei0127-chinaboy@
通讯作者:杨发成,E-mail:1344004157@ ㊃病毒性肝炎㊃
直接抗病毒药物治疗慢性丙型肝炎患者疗效研究∗
李亚玲,杨发成,蒋亚西
㊀㊀ʌ摘要ɔ㊀目的㊀探讨应用直接抗病毒药物(DAAs)治疗慢性丙型肝炎(CHC)患者的疗效㊂方法㊀2019年6月~ 2022年1月我院诊治的CHC患者65例,给予所有患者索非布韦联合利巴韦林或索非布韦联合达拉他韦治疗12w,随访24w㊂计算天冬氨酸氨基转移酶/血小板比值指数(APRI)㊁基于4因子的纤维化指数,使用流式细胞仪检测外周血T淋巴细胞亚群,使用FibroScan诊断仪行肝脏硬度检测(LSM)㊂结果㊀经肝穿刺活检,组织病理学检查诊断ɤF2期肝纤维化者31例,ȡF3期者34例;入组时,ɤF2期与ȡF3期CHC患者在年龄ʌ分别为54(35,62)岁对60(51,67)岁ɔ㊁LSMʌ分别为8.1(6.5,9.0)kPa对17.0(13.1,26.4)kPaɔ㊁APRIʌ分别为0.4(0.3,0.7)对0.9(0.6,1.4)ɔ㊁FIB-4ʌ分别为1.6(0.9, 2.5)对3.7(2.4,5.2)ɔ㊁PLT计数ʌ分别为174(123,217)ˑ109/L对130(93,147)ˑ109/Lɔ和ASTʌ分别为76(56,79)U/L
对62(47,67)U/Lɔ方面,存在显著性差异(P<0.05);在随访结束时,本组65例CHC患者均获得SVR(100.0%);在基线㊁治疗结束和随访结束时,ɤF2期CHC患者外周血CD4+细胞百分比分别为(34.6ʃ2.8)%㊁(41.4ʃ3.4)%和(44.8ʃ
3.7)%,CD4+/CD8+细胞比值分别为(1.1ʃ0.2)㊁(1.3ʃ0.3)和(1.6ʃ0.4),ȡF3期则分别为(3
4.3ʃ3.0)%㊁(39.6ʃ
3.8)%和(41.8ʃ3.7)%,和(1.1ʃ0.3)㊁(1.4ʃ0.3)和(1.6ʃ0.4),均随着治疗而逐渐升高,但两组间无显著性差异(P>
0.05)㊂结论㊀CHC患者存在不同程度的肝纤维化,应用DAAs治疗均可获得很好的疗效,其不仅具有直接抗病毒作用,
可能还具有调节免疫功能紊乱作用㊂
㊀㊀ʌ关键词ɔ㊀慢性丙型肝炎;直接抗病毒药物;持续病毒学应答;肝纤维化;治疗
㊀㊀DOI:10.3969/j.issn.1672-5069.2023.05.009
㊀㊀Virological response to direct acting antivirals in patients with chronic hepatitis C and liver fibrosis㊀Li Yaling,Yang Facheng,Jiang Yaxi.Department of Pharmacy,Huaxi Guang'an Hospital,Sichuan University,Guang'an638500,Sichuan Province,China
㊀㊀ʌAbstractɔ㊀Objective㊀The aim of this clinical trial was to investigate the virological response to direct acting antivirals (DAAs)in patients with chronic hepatitis C(CHC)and liver fibrosis.Methods㊀65patients with CHC were encountered in our hospital between June2019and January2022,all patients underwent liver biopsies at presentation,and the combination of sofosbuvir and ribavirin was given to37patients and the combination of sofosbuvir and daratavir was given to28patients,both lasting for12weeks.All the patients were followed-up for24weeks.The aspartate aminotransferase to platelet ratio index(APRI) and fibrosis index based on the4factors(FIB-4)were obtained,and the liver stiffness measurement(LSM)was measured by FibroScan.The peripheral blood lymphocyte subsets was determined by FCM.Results㊀The liver histopathological examination showed thatɤF2liver fibrosis in31cases andȡF3liver fibrosis in34cases in our series;at admission,there were significant differences as respect to the ages[54(35,62)year old vs.60(51,67)year old],LSM[8.1(6.5,9.0)kPa vs.17.0(13.1, 26.4)kPa],APRI[0.4(0.3,0.7)vs.0.9(0.6,1.4)],FIB-4[1.6(0.9,2.5)vs.3.7(2.4,5.2)],PLT counts[174 (123,217)ˑ109/L vs.130(93,147)ˑ109/L]and AST levels[76(56,79)U/L vs.62(47,67)U/L,all P<0.05]between patients withɤF2andȡF3liver fibrosis;at the end of24week follow-up,the sustained virologic response(SVR)was100.0% in the65patients with CHC;at baseline,the end of treatment and end of follow-up,the percentages of peripheral blood CD4+cells [(34.6ʃ2.8)%,(41.4ʃ3.4)%and(44.8ʃ3.7)%]and the ratio of CD4+/CD8+cells[(1.1ʃ0.2),(1.3ʃ0.3)and(1.6ʃ
0.4)]in patients withɤF2liver fibrosis were not significantly
different compared to[(34.3ʃ3.0)%,(39.6ʃ3.8)%and
(41.8ʃ3.7)%]and[(1.1ʃ0.3),(1.4ʃ0.3)and(1.6ʃ
0.4)]in patients withȡF3liver fibrosis,although they both
increased as the prolongation of the antiviral treatment.
Conclusion㊀The application of DAAs in the treatment of
patients with CHC and different stage of liver fibrosis is
efficacious,which not only by the direct antiviral action,but by
the modulation of immune functions.
㊀㊀ʌKey wordsɔ㊀Hepatitis C;Direct acting antivirals;Sustained virological response;Liver fibrosis;Therapy
㊀㊀丙型肝炎病毒(hepatitis C virus,HCV)感染是一个全球性的健康问题㊂大多数HCV感染者会转变成慢性疾病状态,可能导致慢性肝炎㊁肝纤维化㊁肝硬化,甚至是肝细胞癌(HCC)[1,2]㊂过去,传统标准治疗HCV感染的方法是应用α-干扰素联合利巴韦林(ribavirin,RBV)方案㊂多项研究表明,以α-干扰素为基础方案治疗后获得持续病毒学应答(sustained virological response,SVR)可以有效预防肝功能失代偿㊁降低HCV相关肝硬化和HCC的发生风险㊂此外,该方案还可以改善与肝病相关的生存状况[3-5]㊂然而,以α-干扰素为基础的治疗方案也存在着一定的不良事件发生㊂自从新一代直接抗病毒药物(direct acting antivirals,DAAs)的研制问世以来,治疗慢性丙型肝炎(chronic hepatitis C,CHC)已经进入无干扰素方案时代[6,7]㊂这些DAAs药物是有效的㊁安全的,甚至在老年或肝硬化患者也有很好的耐受性㊂真实世界研究发现DAAs类治疗者SVR依然可以超过95%㊂不过,也有些研究报道了应用DAAs 治疗患者存在HCC发生的潜在风险或HCV相关肝癌进展[8-11]㊂因此,DAAs治疗CHC患者存在着HCC新发或病情复发的不确定性㊂机体的免疫功能在病毒感染和HCC发生发展过程中起着重要的作用㊂应用DAAs清除HCV感染后,机体免疫系统对肿瘤的监测能力可能下降,被认为是病情进展或复发的潜在的发病机制㊂本研究探讨了应用DAAs治疗CHC患者的疗效情况,现报道如下㊂
1㊀资料与方法
1.1病例来源㊀2019年6月~2022年1月我院诊治的CHC患者65例,男37例,女28例;年龄为40~ 69岁,中位年龄为58(46,65)岁㊂诊断符合‘丙型肝炎防治指南“(2019年版)的标准[12]㊂血清HCV RNA载量为6.2(3.0,7.3)lgIU/mL㊂排除标准:合并存在其他嗜肝病毒感染㊁肝内外梗阻性黄疸㊁自身免疫性肝病㊁酒精性肝病或伴有药物滥用史或药物性肝损伤;存在肝性脑病㊁肝肾综合征等肝硬化严重并发症者;既往有肝脏和胆道手术史㊁近半年接受过α-干扰素治疗史;伴有严重的心血管疾病㊁消化性溃疡㊁肝癌等恶性肿瘤者;合并重要器官功能障碍者㊁妊娠或哺乳期妇女㊂所有研究对象签署知情同意书,本研究经我院医学伦理委员会批准㊂1.2治疗方法㊀给予37例CHC患者索非布韦(SOF,美国吉利德公司)400mg口服,1次/d,联合RBV(四川美大康药业股份有限公司)300mg口服, 3次/d,给予28例SOF(同上)联合达拉他韦(中美上海施贵宝制药有限公司)60mg口服,1次/d㊂所有患者均持续治疗12w,随访24w㊂
1.3检测方法㊀采用实时荧光定量PCR法检测血清HCV RNA(中山大学达安基因股份有限公司),停药随访结束时血清HCV RNA载量低于检测下限为SVR;采用基因测序法检测HCV基因型(德国凯杰公司);使用美国贝克曼库尔特公司生产的LH780型全自动血液分析仪检测血常规;使用日本日立公司的7600型全自动生化分析仪检测血生化指标,根据患者年龄㊁肝功能指标和血常规检查结果,计算天冬氨酸氨基转移酶/血小板比值指数(aspartate amin-otransferase-to-platelet ratio index,APRI)㊁基于4因子的纤维化指数(fibrosis index based on the4fac-tors,FIB-4),计算公式为:FIB-4=年龄ˑAST/PLTˑALT1/2;APRI=AST(ULN)/PLT(ˑ109/L)ˑ100(其中ULN为AST的正常参考值上限)[13];使用杭州艾森生物有限公司提供的流式细胞仪检测外周血T淋巴细胞亚群㊂
1.4肝硬度检查㊀使用法国Echosens公司生产的Fi-broScan诊断仪行肝脏硬度检测(liver stiffness meas-urement,LSM)㊂
1.5肝穿刺活检㊀使用美国Bard公司提供的MG15 -22型全自动活检穿刺枪吸取肝组织,置于10%甲醛溶液中固定,常规石蜡包埋,行HE染色,在光学显微镜下观察㊂参照‘肝纤维化诊断及疗效评估共识“作出病理学诊断,其中F1期:汇管区纤维化扩大,纤维化局限于窦周或小叶内;F2期:汇管区周围出现纤维化,并形成纤维间隔,但小叶结构完整;F3期:纤维间隔形成,小叶结构紊乱,无肝硬化;F4期:早期肝硬化或肯定的肝硬化[14]㊂
1.6统计学分析㊀应用IBM SPSS Statistics24.0软件行统计学分析,P<0.05被认为差异有统计学意义㊂对偏态分布的计量资料以ʌM(P25,P75)ɔ表示,采用Mann-Whitney U检验;对正态分布的计量资料以(xʃs)表示,采用独立t检验;计数资料以绝对数表示,采用卡方检验㊂
2㊀结果
2.1不同肝纤维化分期的CHC患者临床资料比较㊀在65例CHC患者中,经肝组织学检查发现ɤF2期31例,ȡF3期34例;入组时,ȡF3期年龄㊁LSM㊁APRI㊁FIB-4㊁PLT和血清AST水平与ɤF2期比,存在显著性差异(P<0.05,表1);在随访结束时,本组患者SVR为100%㊂
表1㊀两组CHC患者临床资料ʌ%,M(P25,P75)ɔ比较
ɤF2期(n=31)ȡF3期(n=34)年龄(岁)54(35,62)60(51,67)①
男性13(41.9)16(47.0)
基因型
㊀1b22(71.0)27(79.4)
㊀2a9(29.0)7(20.6) HCV RNA(IU/ml)6.6(5.8,7.2) 6.3(4.9,6.9) LSM(kPa)8.1(6.5,9.0)17.0(13.1,26.4)①APRI0.4(0.3,0.7)0.9(0.6,1.4)①FIB-4 1.6(0.9,2.5) 3.7(2.4,5.2)①PLT(ˑ109/L)174(123,217)130(93,147)①ALT(U/L)84(58,107)87(55,101) AST(U/L)76(56,79)62(47,67)①
㊀㊀与ɤF2期比,①P<0.05
2.2两组外周血淋巴细胞亚群变化比较㊀在治疗后,所有CHC患者外周血CD4+细胞百分比和CD4+/ CD8+细胞比值上升,但治疗前后两组变化无显著性差异(P>0.05,表2)㊂
表2㊀两组外周血淋巴细胞亚群(xʃs)变化比较
CD4+(%)CD8+(%)CD4+/CD8+比值ɤF2期
㊀㊀基线34.6ʃ2.833.1ʃ3.4 1.1ʃ0.2㊀㊀治疗结束41.4ʃ3.430.8ʃ3.0 1.3ʃ0.3㊀㊀随访结束44.8ʃ3.729.2ʃ2.7 1.6ʃ0.4ȡF3期
㊀㊀基线34.3ʃ3.032.7ʃ3.2 1.1ʃ0.3㊀㊀治疗结束39.6ʃ3.830.1ʃ3.2 1.4ʃ0.3㊀㊀随访结束41.8ʃ3.729.0ʃ2.8 1.6ʃ0.4 3㊀讨论
应用DAAs治疗根除HCV感染的目标是防止肝病进展和改善肝纤维化㊂由于在根除HCV感染后采用连续肝活检检查诊断和监测CHC患者病情变化是不可行的,而许多非侵入性方法被广泛用于评估肝纤维化状态㊂
本研究在应用DAAs进行抗HCV感染治疗后,发现ȡF3期CHC患者在治疗结束时LSM显著下降,并且这种下降趋势在随访结束时仍被观察到,与以前的研究结论描述是相似的㊂有报道称应用
DAAs治疗后,全部CHC患者获得SVR,此时中位LSM下降了30%,其中晚期肝纤维化和肝硬化患者LSM改善程度更为显著[15]㊂在172例丙型肝炎肝硬化患者进行队列研究,经过DAAs治疗后,LSM从基线水平的16.9kPa迅速降低至治疗24w后的11. 9kPa[16]㊂此外,在招募的749例患有F3/F4期肝纤维化的CHC患者,他们的中位LSM从DAAs治疗前的19.3kPa下降到治疗结束时的15.2kPa[17]㊂由此可见,DAAs能够有效改善ȡF3期CHC患者肝纤维化状态并得到证实㊂LSM的改善反映着慢性肝病患者肝纤维化状态的真正消退,或者更确切地说是肝脏炎症的消退㊂不过,有些研究称慢性肝病患者LSM下降并不一定说明肝纤维化的消退,因为后者也会受到机体炎症和脂肪变性的影响㊂此外,DAAs 治疗不同基因型CHC患者的效果存在着差异㊂在本研究纳入的病例,发现DAAs治疗后基因1b型患者LSM呈持续性下降,而在基因2a型患者中并没有观察到类似的变化(资料未列出)㊂
外周血T细胞亚群水平变化可客观地反映机体的免疫功能状态㊂淋巴细胞参与了嗜肝性病毒感染的清除过程以及肝组织损伤反应[18,19]㊂CD4+T细胞能够抑制病毒复制和变异,可有效降低病毒载量,从而减轻机体的免疫损伤,而CD8+T细胞属于细胞毒性亚群,可导致细胞免疫功能紊乱[20,21]㊂本研究结果显示ɤF2期与ȡF3期CHC患者在DAAs治疗后外周血CD4+T细胞以及CD4+/CD8+细胞比值均较治疗前显著上升,这些结果表明经过DAAs的系统治疗能够有效地调节CHC患者机体紊乱的免疫反应,可能也协助了抗病毒治疗应答过程㊂
综上所述,CHC患者存在不同程度的肝纤维化,应用DAAs治疗不同程度肝纤维化的CHC患者均可获得很好的临床疗效,表现为持续性病毒学应答反应,肝功能指标复常,LSM降低提示可有效抑制肝纤维化进程,而纠正了紊乱的免疫功能可能也控制了炎症反应,提高疗效㊂对这些治疗应答患者进行长期随访,将有助于观察其长期疗效以及对减少肝硬
化和肝癌发生方面的作用㊂
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(收稿:2022-07-11)
(本文编辑:陈从新)。