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二维剪切波弹性成像评估不同 ALT 水平慢性肝病患者肝纤维化分期的临床价值

作者： style="font-size: 12px ">王雪梅张瑶王跃龙张记王玥

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出版年,卷(期):页码：2026,18(2):91-95

摘要：

摘要：目的探讨二维剪切波弹性成像（two-dimensional shear wave elastography，2DSWE）评估不同丙氨酸氨基转移酶（alanine aminotransferase，ALT）水平慢性肝病患者肝纤维化分期的临床价值。方法回顾性分析 2018 年 8 月至 2024 年 1 月于首都医科大学附属北京地坛医院行肝脏穿刺活检的 422 例慢性肝病患者的临床资料。所有患者在肝组织穿刺活检术前采用 2D-SWE 测量肝硬度值（liver stif fness measurement，LSM）。根据肝组织病理学分期将患者分为 3 组，＜ S2 期组（272 例）、S2～S3 期组（123 例）、≥ S4 期组（27 例），每组进一步按 ALT 水平分为 ALT 正常组（0～40 U/L）和 ALT 异常组（＞ 40 U/L），比较各组间 LSM 的差异。采用受试者工作特征（receiver operator characteristic，ROC）曲线分析 LSM 对不同 ALT 水平 S0～S3 期患者显著纤维化（≥ S2 期）的诊断效能。结果肝纤维化分期＜ S2 期组（中位数：6.6 kPa 比 5.8 kPa）和 S2～S3 组（中位数：10.6 kPa 比 9.6 kPa）中 ALT 异常者的 LSM 值均显著高于ALT 正常者（Z = - 3.70、P ＜ 0.001；Z = - 2.24、P = 0.03），≥ S4 期组中 ALT 正常者和 ALT 异常者 LSM 值差异无统计学意义（中位数：16.8 kPa 比 17.7 kPa；Z = - 0.70，P = 0.48）。对于 ALT 正常的慢性肝病患者，LSM 诊断显著纤维化（≥ S2 期）的 ROC曲线下面积为 0.846（95%CI：0.79～0.90），最佳截断值为 6.55 Kpa，敏感度为 88.1%，特异度为 68.3%。对于 ALT 异常的慢性肝病患者，LSM 诊断显著纤维化（≥ S2 期）的 ROC 曲线下面积为 0.826（95%CI：0.76～0.89），最佳截断值为 9.95 kPa，敏感度为62.5%，特异度为 88.0%。结论 2D-SWE 在慢性肝病患者肝纤维化分期中具有重要价值，但 ALT 升高可导致 S0～S3 期患者 LSM 假性增高，建议采用 ALT 校正的诊断阈值以提高分期准确性。ALT 对≥ S4 期患者 LSM 的影响程度可能随纤维化微环境的改变而减弱或呈现不同模式，需进一步大样本研究验证。

Abstract: Objective To investigate the clinical value of two-dimensional shear wave elastography (2D-SWE) in evaluating liver f ibrosis staging in patients with chronic liver disease at dif ferent alanine aminotransferase (ALT) levels. Methods The clinical data of 422 patients with chronic liver disease who were diagnosed by liver needle biopsy at Beijing Ditan Hospital, Capital Medical University from August 2018 to January 2024 were retrospectively analyzed. Liver stif fness measurement (LSM) was performed using 2D-SWE in all patients before liver tissue needle biopsy. Patients were divided into three groups according to liver fibrosis staging: ＜ S2 staging group (272 cases), S2～S3 staging group (123 cases) and ≥ S4 staging group (27 cases). Each group was further subdivided into normal ALT group (0～40 U/L) and abnormal ALT group (＞ 40 U/L) based on ALT levels, and dif ferences in LSM between groups were compared. The diagnostic ef f icacy of LSM for liver f ibrosis ≥ S2 staging in patients with chronic liver disease (S0～S3 stage) at dif ferent ALT levels was analyzed by receiver operator characteristic (ROC) curve. Results In ＜ S2 staging group (median: 6.6 kPa vs. 5.8 kPa) and S2～S3 staging group (median: 10.6 kPa vs. 9.6 kPa), LSM values of patients with abnormal ALT were signif icantly higher than those of patients with normal ALT (Z = - 3.70, P ＜ 0.001; Z = - 2.24, P = 0.03). No statistically signif icant dif ference in LSM value was observed between patients with normal ALT and those with abnormal ALT in ≥ S4 staging group (median: 16.8 kPa vs. 17.7 kPa; Z = - 0.70, P = 0.48). For chronic liver disease patients with normal ALT, the area under the ROC curve of LSM for diagnosing fibrosis ≥ stage S2 was 0.846 (95%CI: 0.79～0.90), with an optimal cut-of f value of 6.55 kPa, a sensitivity of 88.1%, and a specif icity of 68.3%. For chronic liver disease patients with abnormal ALT, the area under the ROC curve of LSM for diagnosing f ibrosis ≥ S2 stage was 0.826 (95%CI: 0.76～0.89), with an optimal cut-of f value of 9.95 kPa, a sensitivity of 62.5%, and a specif icity of 88.0%. Conclusions 2D-SWE demonstrated signif icant value in the staging of liver f ibrosis in patients with chronic liver disease. However, elevated ALT might cause false-positive LSM increases in S0～S3 stage, and it is recommended to adopt ALT-adjusted diagnostic thresholds to improve staging accuracy. The impact of ALT on LSM in ≥ S4 stage might be attenuated or present dif ferent patterns along with changes in fibrotic microenvironment, which needed to be verif ied by further large-sample studies.

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