摘要目的 分析ALT升高小于2倍正常值上限(ULN)的慢性乙型肝炎患者肝组织学改变的相关因素,并探讨各因素对临床抗病毒治疗适应证的指导价值.方法选择ALT升高<2×ULN,且经肝活组织检查的152例慢性乙型肝炎患者.用Spearman相关分析、单因素方差分析、受试者工作特征曲线下面积、Logistic逐步回归等方法分析临床上常规指标与肝脏炎症分级(G)和纤维化分期(S)的相关性及其诊断价值.分析指标包括年龄、总胆红素、直接胆红素、球蛋白、白蛋白、总蛋白、ALT、AST、碱性磷酸酶、γ-谷氨酰转肽酶(GGT)、白细胞计数、血小板计数(BPC)和血清HBV DNA载量.结果152例患者均有不同程度肝组织学异常,炎症G2、G3及G4者分别为42例(27.6%)、46例(30.3%)和14例(9.2%);纤维化S2、S3及S4者分别为16例(10.5%)、25例(16.5%)和41例(27.0%).血清白蛋白、白蛋白/球蛋白比值、BPC、白细胞计数和GGT与明显肝组织炎症(G2～4)及明显纤维化(S2～4)显著相关(P值均<0.05).年龄≥40岁组患者明显纤维化与中、重度肝损害者均达70.4%(38/54),高于<40岁组的44.9%(44/98)和38.8%(38/98),x2值分别为18.83和9.09,P值均<0.01.建立Logistic逐步回归方程:预测值P=1/[(1+e-(9.3625-0.1626×白蛋白水平-0.0234×BPC].GGT≥65 U/L判断有无明显肝组织炎症的阳性预测值最高(92.7%),回归方程中预测值≥0.500判断有无明显肝组织炎症的灵敏度最高(83.3%).结论 ALT轻度升高的慢性乙型肝炎的患者大部分存在明显的肝脏组织学改变,年龄≥40岁者发生明显肝纤维化与中、重度肝损害的可能性大.GGT及由BPC和白蛋白构成的Logistic回归方程是预测明显肝组织炎症的较好指标.

abstractsObjective To investigate the relevant factors of liver histological changes in chroonic hepatitis B(CHB)patients with mildly elevated ALT and to explore the clinical values of these factors on anti-viral treatment.Methods A total of 152 CHB patients with mildly elevated ALT(less than 2×ULN)who underwent liver biopsy were included in the study.Correlations between routine laboratory markers,liver histological inflammation grade and fibrosis stage were statistically assessed by Spearman correlation analysis,one-way ANOVA,area under the curve(AUC)of the receiver operating characteristic curves(ROC)and Logistic regression statistical analysis.Results All patients in the study showed various hepatic histological damages. Among the 152 patients 50 (32.9%) were found with inflammation grade 1 (G1),42 (27.6%) with G2,46 (30.3%) with G3 and 14 (9.2%) with G4. 16 patients (10.5%) were found with fibrosis stage 2 (S2),25(16.5%) with S3 and 41 (27.0%) with S4. Routine laboratory markers Alb,BPC and WBC were significantly correlated with hepatic histological inflammation grade and fibrosis stage. Marked liver fibrosis and moderate to severe liver damage were significantly higher in patients aged more than 40 years as compared to those less than 40 years of age (P = 0.002,P = 0.010). The regression equation P = 1/[1+e-(9.3625-0.1625Alb-0.0234BPC)]was established with sensitivity and specificity of 83.3% and 65.0%,respectively. Conclusion 67.8% of CHB patients with mildly elevated ALT have significant injury to the liver tissue. CHB patients aged more than 40 years have a significant increase of marked liver fibrosis and moderate to severe liver damage. The regression equation is valuable to predict whether CHB patients need antiviral therapy or not.