严重急性呼吸道综合征并发肝脏损害的临床特点与机制探讨

目的 探讨严重急性呼吸道综合征(SARS)并发肝脏损害的临床特点,分析其可能的原因,以进一步阐明SARS的发病机制,为临床治疗提供依据。方法 对154例SARS患者,观察了临床症状、体征、肝功能等。其中46例患者系统检测了血清白细胞介素(IL)-1 β、IL-2、IL—4、IL—6、IL—8、IL—10、肿瘤坏死因子(TNF)α、内毒素和甲～戊型肝炎病毒标志物。部分病例进行了肝脏B型超声和病理学检查。另有15例健康者及22例同期住院的慢性肝病患者作为对照。结果 37.7％的SARS患者入院时丙氨酸氨基转移酶(ALT)或/和天门冬氨酸氨基转移酶(AST)升高,其中43.1%轻度升高(<80 U/L),56.9%中度升高。肝功能异常以ATL单项增高为主(70.7％),其次为ALT与AST同时异常(22.4％),少数单纯AST增高。75.9％患者转氨酶在2周内恢复正常,有4例入院时转氨酶正常而在住院过程中升高。重型SARS患者转氨酶异常率显著高于轻型,x~2=19.28,P<0.05。住院期间24.0％患者血清白蛋白下降,28.6％前白蛋白降低,8.4％总胆红素升高,72.7％患者入院时肌酸激酶或(和)心肌型肌酸激酶同功酶异常。IL-1等6种白细胞介素与TNF—α在急性期均显著高于恢复期、正常对照组和慢性肝病组,t=1.67～6.48,P<0.05～0.01。ALT异常组IL-1 β、IL-6和IL-10显著高于ALT正常组,t-2.36～

Clinical characteristics and mechanism of liver injury in patients with severe acute respiratory syndrome

Objective To summarize the clinical features of liver injury in patients with severe acute respiratory syndrome (SARS), providing information for further mechanism and clinical study. Methods The clinical and some laboratory data of 154 patients suffered from SARS were collected and analyzed, who were admitted to the isolation wards of Beijing You'an Hospital from march 11 to june 3, 2003. The serum samples were taken from 46 patients to detect IL-1B, IL-2, IL-4, IL-6, IL-8, IL-10,TNF-a, endotoxin and hepatitis related viral inclusions. In addition, 11 patients were detected ultrasonically, and 3 patients were described pathological features. Other two groups including 15 healthy care workers and 22 patients with chronic hepatitis in the same period were selected and analyzed as controls. Results When being admitted to hospital, serum ALT and (or) AST levels were elevated in 37.7% SARS patients. Some of them (43.1%) were mild, and most of them (56.9%) were moderate. Abnormal liver function mainly resulted from ALT elevation (70.7%), then both ALT and AST elevation (22.4%). The aminotransferases in 75.9% SARS patients normalized within two weeks, while they elevated in four patients during the hospitalization. There was a significant difference in ALT/AST elevation rates between severe and mild clinical type (x2 =19.28, P < 0.05). Serum total bilirubin values elevated in 8.4% patients. Serum albumin and prealbumin levels decreased in 24.0% and 28.6% patients, respectively. Creatine kinase (CK) and (or) creatine kinase MB (CK-MB) levels elevated in 72.7% patients when they hospitalized. The six kinds of interleukins and TNF- a levels during the first week of hospitalization were higher than those in the fourth week and in control groups (t > 1.67, P < 0.05). The levels of some factors, such as IL-1 (3, IL-6 and IL-10 in patients with elevated ALT, were higher than those in ALT normal patients (t > 2.36, P < 0.05). In the first week, only 15.2% patients had elevated serum endotoxin level. Ultrasonic examination and pathological observation showed no special features, compared with those in common acute hepatitis patients. Conclusions All the results suggest strongly that there may be a systemic inflammatory response syndrome (SIRS) in most SARS patients in early stage, and the liver damage is only its partial signs. It may be beneficial to suppress cytokines storm in SARS patients in early stage, which will stop the progression of SIRS and release hepatic damage and improve the prognosis of SARS patients.