慢性乙型肝炎合并非酒精性脂肪肝的临床特征分析
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摘要：目的 分析慢性乙型肝炎(CHB)合并非酒精性脂肪肝(NAFLD)的特征，为预防NAFLD的发生提供干预对策。方法 随机抽取2018年6月至2021年6月联勤保障部队第九〇四医院收治的CHB患者348例，根据是否患有NAFLD分为实验组(CHB合并NAFLD,n=195)和对照组(CHB,n=153),收集研究对象年龄、性别、BMI(kg/m2)、糖尿病病史、高血压病史、饮酒史等基本资料；收集肝功(AST、ALT、GGT、ALP、ALB)、血脂(TG、LDL-C)、空腹血糖(FBG)等血清学指标以及乙肝病毒定量(HBVDNA)等病毒学指标，采用logistic回归分析方法筛选CHB患者发生NAFLD的独立危险因素。结果 研究共纳入CHB患者348例，其中合并NAFLD患者共195例(56.03%)。实验组N AFLD高发年龄段为30～45岁163(46.84%);男性发病率70.81%(131/195)显著高于女性发病率39.26%(64/195),差异具有统计学意义(χ2=35.005,P<0.05);患者在年龄<30岁和30～45岁时，男性NAFLD发病率显著高于女性发病率(χ2=10.625,χ2=20.238,P<0.05);患者在年龄>45岁时，男性和女性NAFLD发病率差异无统计学意义(χ2=2.005,P>0.05);两组高血压病史、ALT、ALP间差异无统计学意义(P>0.05)。两组年龄、性别、BMI、糖尿病病史、饮酒史、AST、TG、LDL、FBG和FBG间差异具有统计学意义(P<0.05)。logistic回归分析结果显示BMI、AST、FBG、TG升高是CHB患者发生NAFLD的独立危险因素(P<0.05)。结论 CHB患者发生NAFLD的风险较高，BMI、AST、FBG、TG升高是CHB患者发生NAFLD的独立危险因素。
关键词：慢性乙型肝炎 非酒精性脂肪肝 干预对策
Characteristics and intervention strategies of chronic hepatitis B complicated with nonalcoholic fatty liver disease
PEI Xiao-hong ZHU Xiao-xuan WANG Ting-ting ZHU Qing
Department of Gastroenterology,Suzhou Medical District,Joint Logistics Support Force 904th Hospital; Department of Gastroenterology,Eastern Theater Air Force Hospital of the Chinese People′s Liberation Army;
Abstract：Objective To analyze the characteristics of chronic hepatitis B(CHB) complicated with non-alcoholic fatty liver disease(NAFLD),and to provide countermeasures for the prevention of NAFLD. Methods A total of 348 patients with CHB admitted to our hospital from June 2018 to June 2021 were randomly selected and divided into experimental group(CHB combined with NAFLD,n=195) and control group(CHB,n=153) according to whether they had NAFLD or not.Basic data such as age, sex, BMI(kg/m2),history of diabetes, history of hypertension, and history of alcohol consumption were collected.Serum indexes such as liver function(AST,ALT,GGT,ALP,ALB),blood lipid(TG,ldl-c),fasting blood glucose(FBG) and virological indexes such as hepatitis B virus(HBV DNA) were collected. Results A total of 348 CHB patients were included in the study, including 195(56.03%) patients with NAFLD.The high NAFLD incidence age was between 30 and 45 years old(163 cases, 46.84%).The incidence of NAFLD in male(131 cases, 70.81%) was significantly higher than that in female(64 cases, 39.26%)(χ2=35.005,P<0.05).The incidence of NAFLD in male patients was significantly higher than that in female patients at age <30 and 30～45(χ2=10.625,χ2=20.238,P<0.05).There was no significant difference in the incidence rate of NAFLD between men and women at age >45 years(χ2=2.005,P>0.05).There were no significant differences in the history of hypertension, ALT and ALP between the two groups(P>0.05).The differences in age, sex, BMI,history of diabetes, history of alcohol consumption, AST,TG,TG,FBG and FBG between the two groups were statistically different(P<0.05).Logistic regression analysis showed that increased BMI,AST,FBG and LDL were independent risk factors for NAFLD in CHB patients(P<0.05). Conclusions CHB with NAFLD often has glucolipid metabolic disorder, which is related to increased body mass index and AST.It is suggested that we should strengthen the health management of patients with high blood pressure, diabetes, overweight, and obesity, guide patient to balance their diet, adjust their diet structure, control their body weight and glycolipid abnormalities, adjust body fat, reduce blood pressure by drugs, and control blood sugar in a timely manner, and maintain a healthy lifestyle.
Keyword：Chronic hepatitis B; Nonalcoholic fatty liver disease; Intervention strategy;
慢性乙型肝炎(CHB)是一种常见的慢性传染病，随着肥胖、高脂血症、糖尿病、饮食结构的该病等因素，慢性乙型肝炎(CHB)合并非酒精性脂肪肝(NAFLD)的发病率逐渐升高[1]。NAFLD和CHB已成为我国最主要的慢性肝病，研究表明CHB患者合并肝脂肪变的发生率在15%左右[2]。NAFLD 的具体发病机制尚不明确，宿主的代谢紊乱和病毒因素与NAFLD的发生和发展密切相关[3]。CHB患者发生NAFLD多与肥胖、糖脂代谢异常等因素相关，故研究分析CHB合并NAFLD的特征，为预防NAFLD的发生提供干预对策。
1 对象与方法
1.1 样本
选取2018年6月至2021年6月来院就诊的CHB患者348例，其中男性197例，女性151例，平均年龄为(37.69±6.84)岁。诊断标准：符合《慢性乙型肝炎防治指南》中关于CHB的诊断标准[4],有HBsAg 阳性史或乙型肝炎病史>6个月，HBV DNA仍为阳性和(或)HBsAg阳性者；符合《非酒精性脂肪性肝病诊疗指南》中关于NAFLD的诊断标准[5];患者均签署知情同意书。排除标准：合并肝癌、自身免疫性肝病等慢性肝病患者；患者合并恶性肿瘤、内分泌疾病、血液系统疾病等疾病；伴有甲状腺功能异常、垂体功能异常、库欣综合征等可引起体重及食欲改变的继发性因素；近期服用药物如类固醇药物等；肝活组织检查不符合病理诊断标准或已接受抗病毒治疗者。根据是否患有NAFLD分为实验组(CHB合并NAFLD,n=195)和对照组(CHB,n=153),对照组男性66例，女性87例，平均年龄为(35.45±6.51)岁。实验组男性131例，女性64例，平均年龄为(39.45±7.26)岁。
1.2 实验方法
收集研究对象年龄、性别、BMI(kg/m2)、糖尿病病史、高血压病史、饮酒史等基本资料；抽取所有患者空腹肘静脉血5mL,测定患者肝功(AST、ALT、ALP、ALB)、血脂(TG、LDL-C)、空腹血糖(FBG)等血清学指标以及乙肝病毒定量(HBVDNA)等病毒学指标水平。采用logistic回归分析方法筛选CHB患者发生NAFLD的独立危险因素。
1.3 统计学方法
采用SPSS 25.0软件进行数据处理，计量资料采用t检验，计数资料比较选用 χ2 检验，相关性分析采用非条件logistic回归分析，以P<0.05表示差异有统计学意义。
2 结 果
2.1 CHB合并NAFLD患者临床特征
研究共纳入CHB患者348例，其中合并NAFLD患者共195例(56.03%),NAFLD高发年龄段为30～45岁163例(46.84%);其中男性NAFLD发病率131例(70.81%)显著高于女性发病率64例(39.26%),差异有统计学意义(χ2=35.005,P<0.05);患者在年龄<30岁和30～45岁时，男性NAFLD发病率显著高于女性发病率(χ2=10.625,χ2=20.238,P<0.05);患者在年龄>45岁时，男性和女性NAFLD发病率差异无统计学意义(χ2=2.005,P>0.05)。
2.2 CHB合并NAFLD的单因素分析
两组高血压病史、ALT、ALP间差异无统计学意义(P>0.05)。两组年龄、性别、BMI、糖尿病病史、饮酒史、AST、TG、LDL、FBG和FBG间差异具有统计学意义(P<0.05)。
表1 不同性别CHB患者NAFLD发病情況比较[n(%)]
表2 CHB合并NAFLD的单因素分析
2.3 CHB合并NAFLD的多因素logistic回归分析
以是否发生NAFLD为因变量，以具有差异的指标作为自变量进行logistic回归分析，结果显示BMI、AST、FBG、TG升高是CHB患者发生NAFLD的独立危险因素(P<0.05)。
表3 CHB合并NAFLD的多因素logistic回归分析
3 讨 论
NAFLD是一种代谢相关性疾病，其发病率逐年升高，特别是CHB患者常伴肥胖、糖脂代谢异常等因素，发生NAFLD的风险升高[6]。CHB患者发生NAFLD的病因和具体机制尚不完全清楚，多认为与肥胖、糖尿病、高脂血症等因素相关，故此研究分析CHB合并NAFLD的特征，为预防NAFLD的发生提供干预对策。
研究结果显示研究共纳入CHB患者348例，其中合并NAFLD患者共195例(56.03%),高发年龄段在30～45岁，男性NAFLD发病率131例(70.81%)显著高于女性发病率64例(39.26%)(P<0.05);患者在年龄<30岁和30～45岁岁时，男性NAFLD发病率显著高于女性发病率(P<0.05);患者在年龄>45岁时，男性和女性NAFLD发病率差异无统计学意义(P>0.05),与徐亮等人研究结果相一致[7],30～45年龄段人群作责任较大，多自持年轻体健，缺乏锻炼，不注重合理的结构饮食等因素有关[8]。男性发病率高考虑男性膳食不均衡、饮酒、在外就餐较多、生活不规律、缺少体育锻炼等密切有关[9]。logistic 回归分析结果显示BMI、AST、FBG、TG升高是CHB患者发生NAFLD的独立危险因素(P<0.05),AST 与肝组织纤维化程度密切相关，AST水平升高是NAFLD 患者出现进展性肝纤维化的重要因素[10]。由于BMI高的人群脂肪组织量增多，在体内合成三酰甘油较易进行，三酰甘油的合成增多，当极低密度脂蛋白的分泌速度明显低于三酰甘油的合成速度时，过剩部分的三酰甘油沉积于肝脏，引发NAFLD[11]。BMI高的人群应控制饮食，增加运动，保持健康的生活方式[12-13]。FBG升高的患者对葡萄糖的利用发生障碍，需从脂库中动员出大量脂肪，是以脂肪酸的形式进入肝脏，从而导致肝合成的脂肪量增多，超出了合成脂蛋白输送出去和肝脏将脂肪氧化利用的能力，导致脂肪在肝内发生蓄积，引发NAFLD,对于血糖异常的CHB患者应积极进行降糖治疗，合理膳食，控制体重[14-18]。高脂血症患者血液中游离脂肪酸水平增加，在肝细胞内脂肪发生蓄积，肝细胞脂肪变性，从而形成NAFLD,对于血脂异常的CHB患者应积极治疗，科学饮食，保持健康的生活习惯[19-20]。
综上所述，CHB 合并NAFLD常发生糖脂代谢紊乱，CHB 患者发生NAFLD的风险较高，BMI、AST、FBG、TG升高是CHB患者发生NAFLD的独立危险因素，患者应控制糖脂异常，及时进行调脂、控制体重、药物降压、控制血糖治疗，保持健康的生活习惯。
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