원저 Lab Med Online Vol. 9, No. 3: , July 진단면역학 만성 B 형및 C 형간염환자의간섬유화진단을위한비침습적혈액표지자평가 Evaluation of

원저 Lab Med Online Vol. 9, No. 3: 153-16, July 219 진단면역학 만성 B 형및 C 형간염환자의간섬유화진단을위한비침습적혈액표지자평가 Evaluation of Noninvasive Liver Fibrosis Blood Markers in Patients with Chronic Hepatitis B and Hepatitis C 이종한 조주영 김주원 어영 윤갑준 Jong-Han Lee, M.D., Jooyoung Cho, M.D., Juwon Kim, M.D., Young Uh, M.D., Kap Jun Youn, M.D. 연세대학교원주의과대학진단검사의학교실 Department of Laboratory Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea Background: Liver fibrosis evaluation is an important issue in chronic liver disease patients. We aimed to develop noninvasive liver fibrosis biomarkers based on transient elastography (TE, FibroScan ) through retrospective review of clinicopathological data. Methods: We recruited 278 chronic hepatitis B patients who underwent Fibroscan and HBV DNA testing. A total of 115 HBeAg-positive and 159 HBeAg-negative chronic hepatitis B patients were analyzed. A total of 1 hepatitis C patients were analyzed. Successful fibroscan data, gammaglutamyl transferase (GGT) to platelet ratio (GPR), platelet count, AST, ALT, international normalized ratio of prothrombin time, total cholesterol, triglycerides, bilirubin, mean platelet volume, AST to platelet ratio index, fibrosis index based on four factors (FIB-4), neutrophil to lymphocyte ratio (NLR), and NLR to platelet ratio were analyzed to determine the new noninvasive markers for assessing liver fibrosis. Results: Elevated GPR (OR=9.1, P =.11) and FIB-4 (OR=2.3, P =.1) were associated with greater risk of liver fibrosis in chronic hepatitis B patients. FIB-4 (OR=6.4, P =.5) was a risk factor for liver fibrosis in HBeAg-positive patients. FIB-4 (OR=2.371, P =.15) and GPR (OR=33.78, P =.3) were liver fibrosis risk factor in HBeAg-negative patients. In chronic hepatitis C patients, GGT (OR=1.33, P =.2), triglyceride (OR=.99, P =.38) and FIB-4 (OR=3.499, P =.6) showed statistical significances. The AUCs were.816 in FIB-4 (P <.1) and.849 in GPR (P <.1). Conclusions: FIB-4 and GPR may be useful blood markers for assessing liver fibrosis in chronic hepatitis B and hepatitis C patients. Further well-designed prospective study is required to validate these noninvasive blood markers in clinical practice. Key Words: Liver fibrosis, Hepatitis B, Hepatitis C, Fibroscan, Noninvasive marker 배경 간섬유화는만성간질환의질환정도를파악하는매우중요한 근거로섬유화의진행정도를파악하는여러가지노력이지속되 Corresponding author: Jong-Han Lee, M.D., Ph.D. https://orcid.org/-3-436-8443 Department of Laboratory Medicine, Yonsei University Wonju College of Medicine, 2 Ilsan-ro, Wonju 26426, Korea Tel: +82-33-741-1594, Fax: +82-33-731-56, E-mail: cello425@yonsei.ac.kr Received: September 28, 218 Revision received: November 9, 218 Accepted: December 13, 218 This article is available from http://www.labmedonline.org 219, Laboratory Medicine Online This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4./) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 고있다. 간섬유화를평가하는방법으로현재까지도기준검사는간조직생검이다. 그러나가장정확하다고알려진간조직검사의경우침습적이고고비용이며, 낮은빈도이긴하지만출혈과기타부작용이있으며반복측정이어렵다는단점을갖고있다 [1]. 따라서영상의학검사와혈액검체검사등을이용한비침습적지표등이널리활용되고있다. 실제임상에서는영상의학검사를널리활용하는편이다. 영상의학검사중간탄력도검사 (transient elastography, TE) 는비교적쉽게접근이가능하고객관적이며반복측정이용이하다는장점을갖고있다 [2-7]. 하지만비만환자이거나 ALT 등의간효소수치증가시의해석이용이하지않다는몇가지단점은해결해야할숙제이다 [2, 8, 9]. 따라서혈액학적표지자의추가검사를통한진단민감도의향상은진단정확도를향상시키는중요한도구로고려해볼수있겠다. 본연구에서는간탄력도검사를기준으로여러항목의혈액표지자를만성 B형및만성 C형간염환자군에서간탄력도검사와비교분석해봄으로써이들혈액표지자 eissn 293-6338 www.labmedonline.org 153

의비침습적진단표지자로서의활용가능성을제시하고자하였다. 연구방법 간탄력도검사를시행받은환자를대상으로이를크게만성 B형간염군, HBeAg양성 B형간염군, HBeAg 음성 B형간염군및만성 C형간염군으로구별하였다. 각질환별로간탄력도검사를기준으로유의한차이를보이는혈액지표를제시하고자하였다. 29년 4월부터 217년 6월까지총 278명의간탄력도검사를받은환자를대상으로분석하였다. 간탄력도검사는다음의세가지기준을충족하였을때유효한검사로간주하였다. 첫째, 최소 1회이상의측정, 둘째, 간경화도측정지수 (liver stiffness measurement) 사분위값을중위수로나눈비율 (IQR/M) 이.3보다작은경우, 셋째, 간탄력도검사의성공률이 6% 이상의경우였다. 간탄력도검사의참고치는초기간섬유화는 5.3 kpa, 중등도간섬유화의판단기준을 7.2 kpa로설정하였는데이는간탄력도검사관련선행연구를진행하였던 Kim 등 [6] 과 Marcellin 등 [1] 의연구를참고하여정하였다. 구체적으로는간탄력도검사결과의해석은정상수준은 <5.3 kpa, 경도간섬유화는 5.3 <7.2 kpa, 중등도간섬유화는 7.2 <9.4 kpa, 중증간섬유화는 9.4 <12.1 kpa, 간경변은 12.2 kpa 로설정하였다. 분석혈액지표로는혈소판수 ( 참고치 : 165 36 1 9 /L), 평균혈소판용적 ( 참고치 : 6.4 9.7 fl), INR ( 참고치 :.92 1.13), gamma glutamyl transferase (GGT) ( 참고치 : 남자, <6; 여자, <4 U/L), 총콜레스테롤 ( 참고치 : <5.2 mmol/l), 중성지방 ( 참고치 : <2.26 mmol/ L), aspartate transaminase (AST) ( 참고치 : <4 U/L), alanine transaminase (ALT) ( 참고치 : <4 U/L) 와빌리루빈 ( 참고치 : <22 μmol/ L) 을분석하였다. 또한계산지표로 AST 대 ALT 비율, AST 대혈소판비율 (APRI) [1 AST (U/L)/ 본원검사실참고범위 [ 남자는 4 (U/L), 여자는 35 (U/L)/ 혈소판수 (1 9 /L)], GGT 대혈소판비율 (GPR) [1 GGT (U/L)/ 본원검사실참고범위 [ 남자는 6 (U/L), 여자는 4 (U/L)/ 혈소판수 (1 9 /L)], 중성구수대림프구수비율 (NLR), NLR 대혈소판비율과 FIB-4 점수를확인하였다. FIB-4는 나이 AST/ 혈소판수 ALT 1/2 으로계산하였다. Table 1에계산지표들의수식을별도로정리하였다. HBeAg 표현에따른차이를확인하고자, 총 115명의 HBeAg 양성및 159명의 HBeAg 음성환자를구별하여분석하였고, C형간염군을대상으로는총 1명의 HCV 유전자형분석을진행한대상군을확인하여간탄력도검사를기준으로비침습적간섬유화혈액지표를발굴하고자하였다. 간탄력도검사는섬유화유무를기준으로분석하고자섬유화초기단계의 cut-off 5.3 kpa를기준값으로설정하였다. 1. 통계방법통계분석은 SPSS version 23. (SPSS Inc., Chicago, IL, USA) 을이용하였다. 변수들의정규성검정을 Kolmogorov Smirnov 검사로확인하였고, 간탄력도검사결과에따른지표별차이를확인하며, 로지스틱회귀분석으로지표별간섬유화위험도를산출하였다. 또한 receiver operating characteristic (ROC) 커브분석을통하여도출된비침습적표지자의민감도특이도를비교분석하였다. 결과 1. 만성 B형간염환자 대상지표별기본분석결과를 Table 1에제시하였다. 간탄력도결과와유의한상관성을보여주는측정지표로는 GGT, AST, ALT, 혈소판수및 INR이었고 (r>±.4), 계산지표로는 APRI, GPR 및 FIB-4이었다 (r>.67). 대표적으로 GGT, GPR, FIB-4의박스분포는간섬유화정도가높을수록증가하였으며혈소판수는감소하였다 (Fig. 1). 간탄력도측정결과를기준으로분석한결과간탄력도결과가증가할수록혈소판은감소경향을보여주었고, AST, ALT 그리고 FIB-4는증가하였다. FIB-4와 GPR은경도의간섬유화범위 (LSM 5.3 <7.2 kpa) 때가정상군 (LSM<5.3 kpa) 보다높았다 (FIB-4: 1.6±.57 vs. 1.54±1.2, P =.3/GPR:.25±.27 vs..43±.48, P =.18). 경도의간섬유화그룹과중등도의간섬유화그룹 (LSM 7.2 kpa) 간에는, 중등도간섬유화그룹에서 GGT Table 1. Summary of calculated biomarkers for liver fibrosis expectation Calculated biomarkers APRI FIB-4 age AST (U/L)/platelet count ALT 1/2 GPR NLR NLR to platelet count Calculation formula [1 AST (U/L)/ULN (4 (U/L) for male, 35 (U/L) for female/platelet count (1 9 /L)] [1 GGT (U/L)/ULN (6 (U/L) for male, 4 (U/L) for female)/platelet count (1 9 /L)] Neutrophil/lymphocyte Neutrophil/lymphocyte/platelet count Abbreviations: APRI, AST to platelet ratio index; ULN, upper limit of normal; FIB-4, fibrosis index based on four factors; GPR, GGT to platelet ratio; GGT, gamma-glutamyl transferase; NLR, neutrophil to lymphocyte ratio. 154 www.labmedonline.org

9 8 7 6 5 4 3 2 1 GGT (U/L) 1 2 3 4 5 Group 6 5 4 3 2 1 Platelet ( 1 9 /L) 1 2 3 4 5 Group 3 25 2 15 1 5 FIB-4 1 2 3 4 5 Group 18 16 14 12 1 8 6 4 2 GPR 1 2 3 4 5 Group Fig. 1. Box plot of gamma glutamyl transferase (GGT), platelet count, FIB-4 and GPR in chronic hepatitis B patients. (.43±.48 vs. 1.38±1.83 U/L), AST (34±19. vs. 18±219 U/L), ALT (41±37 vs. 144±363 U/L), INR (1.2±.6 vs. 1.12±.16), 평균혈소판용적 (8.±.7 vs. 8.5±.9 fl), APRI (.5±.39 vs. 2.27 ±5.47), FIB-4 (1.6±1. vs. 3.5±3.4), GPR (.43±.48 vs. 1.38± 1.8) 및 NLR 대혈소판수 (.9±6 vs..13±.1) 가높았고 (P <.1), 혈소판수 (198±59 vs. 156±71 1 9 /L, P <.1) 와콜레스테롤 (177±35 vs. 166±33, P =.33) 의경우는더낮았다 (Table 2). 다중로지스틱회귀분석에서 FIB-4 (OR=2.3, 95% CI: 1.2 4.2, P =.1) 와 GPR (OR = 9.1, 95% CI: 1.7 5., P =.11) 이간탄력도검사에서간섬유화 (TE, 5.3 kpa) 여부를정상간 (TE, <5.3 kpa) 대비통계적으로유의한위험도를보여주었다. ROC 커브분석에서는 GPR이.84, FIB-4가.82의곡선하면적 (area under the curve) 을보여주었다 (Fig. 2). 간탄력도검사간섬유화 (TE, 5.3 kpa) 기준으로확인해본 FIB-4와 GPR의진단민감도, 진단특이도, 양성예측도, 음성예측도그리고 AUC 값을 Table 3에정리하였다. 2. 만성 B형간염환자에서 HBeAg에따른차이 LSM 수준, 평균혈소판용적 (MPV), HBV DNA 수준은 HBeAg 양성자가음성자보다더높았다. 나이는 HBeAg 음성자가양성자보다더많았고, 중성구림프구비율 (NLR) 은더높았다 (Table 4). TE 의 cut-off를 5.3 kpa로설정한경우 FIB-4 (OR= 6.4, P =.5) 가 HBeAg 양성자에서간섬유화위험도를높였으며, 이에비해 HBeAg 음성자에서는 GPR (OR =33.78, P =.3) 과 FIB-4 (OR=2.371, P =.15) 가간섬유화위험도를의미있게상승시키는것으로확인되었다. 3. 만성 C형간염환자만성 HCV 감염자는유전자형 1b 54명, 유전자형 2a 46명을분석하였다 (Table 5). 유전자형별로다른지표들은통계적인유의미한차이를보이지않았으나 INR의경우유전자형 2a (1.3±.9) 가유전자형 1b (1 ±.7) 보다유의하게높은값을보였다 (P =.47). LSM 5.3 kpa를기준으로 5.3 kpa 이상은총 74명, 5.3 kpa 미만은 26명이었다. AST, ALT, GGT, Bilirubin, MPV, INR, APRI, FIB-4, GPR, NLR to platelet ratio의값은 LSM 5.3 kpa 이상군에서 5.3 kpa 미만군보다높았다. 이에비해, 총콜레스테롤, 중성지방과혈소판의수는 LSM 5.3 kpa 이상군에서 5.3 kpa 미만군보다더낮았다. 간탄력도검사기준 5.3 kpa 적용시간섬유화정도를정상간 ( 간탄력도검사 <5.3 kpa) 대비확인하는다중로지스틱회귀분석에서는 GGT (OR =1.33, P =.2), TG (OR =-.99, P =.38) 및 FIB-4 (OR =3.499, P =.6) 가통계적으로유의하게도출되었다. ROC 커브분석에서는 FIB-4가.816 (P <.1), GPR이.849 (P <.1) 의곡선하면적을보여주었다. www.labmedonline.org 155

Table 2. Levels of parameters according to different liver stiffness measurement levels measured by transient elastography Scale of liver stiffness measurement (kpa) <5.3 kpa 5.3 <7.2 kpa 7.2 <9.4 kpa 9.4 <12.2 kpa 12.2 kpa Number 6 54 38 34 92 Age 44±12.9 (2 81) 46.8±11.1 (19 73) 46.7±12 (25 78) 46.9±9.7 (29 66) 49.5±1.4 (15 81) Gender ratio (Male/Female) 1.3 (34/26) 1.7 (34/2) 1.1 (2/18) 1.3 (19/15) 3 (69/23) HBeAg (Positive/Negative).3 (13/47).6 (2/34).5 (13/25).9 (16/18) 1.4 (54/38) Liver stiffness measurement (kpa) 4±.69 (2.4 5.2) 6.3±.54 (5.3 7.1) 8.14±.67 (7.2 9.3) 1.72±.87 (9.4 12) 24.92±12.82 (12.2 72) Inter quartile range.57±.25 (.1 1.1).76±.33 (.1 1.6) 1.6±.4 (.3 2) 1.31±.58 (.3 2.7) 2.74±1.73 ( 1.7) Success rate (%) 93.4±11 (6 1) 96.6±7.6 (71 1) 97.5±8.14 (63 1) 98.6±4.3 (8 1) 96.6±7.6 (67 1) Platelet ( 1 9 /L) 23.9±51.3 (128 358) 197.8±59.1 (66 321) 194.3±81.6 (62 547) 188.7±63 (77 339) 128.5±55.4 (44 395) GGT (U/L) 28±26.4 (6 146) 38.6±32.7 (9 153) 58.4±82.3 (7 525) 71±49.6 (8 23) 114±115.4 (15 89) Cholesterol (mg/dl) 18.6±3.1 (118 253) 177.2±35.4 (91 28) 172.9±37.3 (12 318) 174.2±28.4 (124 236) 159.7±32.6 (88 235) AST (U/L) 3.3±32.6 (12 265) 33.6±19 (17 135) 58.1±5.1 (2 242) 57.4±4.9 (18 178) 147.1±283.8 (19 2255) ALT (U/L) 4.4±93 (8 738) 4.7±36.8 (6 229) 81.1±96.4 (1 445) 69±71.9 (11 34) 198.2±473.5 (12 369) INR (sec) 1.1±.6 (.86 1.16) 1.2±.6 (.9 1.16) 1.6±.12 (.92 1.7) 1.5±.5 (.96 1.16) 1.16±.19 (.91 2.52) Bilirubin (mg/dl).74±.33 (.17 1.7).83±.42 (.3 2.22).74±.35 (.3 1.8).69±.33 (.2 1.52) 1.45±2.11 (.3 14.41) HBVDNA (IU/mL) 2,51,759±9,852,121.6 (22 61,3,) 7,517,113.8±29,539,919.9 (24 17,,) 16,979,6.8±45,423,67 (36 17,,) 11,9,288.5±4,473,294.1 (23 17,,) 9,871,52.5±2,958,659.1 (37 132,,) Triglyceride (mg/dl) 14.3±53.2 (29 277) 99.3±49.8 (42 239) 84.8±37.8 (32 198) 93.7±29.7 (46 169) 94.3±43 (28 282) MPV (fl) 7.918±.748 (6.4 1) 7.989±.715 (6.2 9.4) 8.113±.767 (6.3 9.9) 8.147±.827 (6.4 1.5) 8.762±.882 (7 11.2) Neutrophil (%) 55.9±8.5 (38.1 74.9) 53.3±8.2 (37.7 68.1) 52.5±8.7 (36.3 71.3) 5.9±1.6 (31.9 74.6) 52.3±1.5 (27.5 8.5) Lymphocyte (%) 34±7.2 (18.6 49.8) 36±7.7 (19.6 5.6) 36.8±7.6 (19.8 52.8) 38.2±1.1 (16.8 56.8) 35.2±9.6 (11.8 59.5) AST/ALT 1.4±.42 (.36 2.5) 1.4±.47 (.45 3.17) 1.2±.65 (.44 4) 1.8±.59 (.48 3.14) 1.14±.72 (.37 4.8) APRI.37±.398 (.96 3.125).498±.394 (.169 2.836).913±.92 (.274 4.327).873±.624 (.174 2.565) 3.348±7.11 (.181 53.184) FIB-4 1.63±.573 (.266 2.591) 1.539±1.19 (.379 5.756) 2.22±1.87 (.527 8.89) 2.23±1.127 (.4 5.833) 4.657±3.961 (.736 27.84) GPR.251±.266 (.59 1.83).43±.485 (.8 2.47).689±.889 (.65 5.435).821±.655 (.51 3.76) 1.878±2.225 (.95 16.245) NLR 1.778±.665 (.765 4.27) 1.64±.64 (.751 3.474) 1.549±.633 (.688 3.61) 1.534±.841 (.562 4.44) 1.716±.954 (.476 6.822) NLR/platelet.8±.4 (.3.2).9±.6 (.3.44).9±.5 (.3.25).1±.9 (.2.39).16±.12 (.2.71) Abbreviations: GGT, gamma-glutamyl transferase; AST, aspartate aminotransferase; ALT, alanine aminotransferase; INR, international normalized ratio of prothrombin time; MPV, mean platelet volume; APRI, AST to platelet ratio index; FIB-4, fibrosis index based on four factors; GPR, GGT to platelet ratio; NLR, neutrophil to lymphocyte ratio. 156 www.labmedonline.org

Table 3. Diagnostic sensitivity, specificity, positive predictive value and negative predictive value of FIB-4 and GPR for liver fibrosis prediction Parameters Sensitivity (%) Specificity (%) PPV (%) NPV (%) AUC P value FIB-4 (cut-off: 1.571) 65.1 86.7 86.7 86.7.82 <.1 GPR (cut-off:.299) 79.4 83.3 83.3 83.3.84 <.1 Abbreviations: FIB-4, fibrosis index based on four factors; PPV, positive predictive value; NPV, negative predictive value; GPR, gamma-glutamyl transferase to platelet ratio; AUC, area under the curve. Table 4. Characteristics of baseline parameters according to HBeAg status HBeAg positive (N=115) HBeAg negative (N=159) P value Age (yr) 45.4±11.9 48.3±1.9.37 Sex ratio (Male:Female) 1.7 (73:42) 1.7 (1:59).921* Liver stiffness measurement (kpa) 14.751±11.156 1.757±1.683.3 AST (U/L) 95.8±142.3 63±193.124 ALT (U/L) 132.5±268 8.5±32.5.142 GGT (U/L) 68.3±58.2 63.7±94.2.644 Total Bilirubin (mg/dl).9±.55 1.5±1.63.344 Total Cholesterol (mg/dl) 17.5±3.8 172.1±35.4.696 Triglyceride (mg/dl) 94.5±41.9 97.4±47.5.65 Platelet count ( 1 9 /L) 174.1±73.6 186.4±7.1.163 Mean platelet volume (fl) 8.41±.86 8.17±.88.22 Prothrombin time, INR 1.9±.12 1.7±.16.265 HBV DNA (IU/mL) 21,28,24.8±41,665,244.9 591,15.9±3,276,928.3 <.1 AST/ALT ratio 1.11±.71 1.4±.46.282 APRI 1.747±2.596 1.345±5.241.449 FIB-4 2.958±2.799 2.275±2.879.5 GPR.9±.813.922±1.777.889 NLR 1.53±.74 1.753±.829.2 NLR/platelet count.11±.8.12±.1.39 *Pearson s chi-square test. Statistical significant P values were printed in bold. Abbreviations: AST, aspartate aminotransferase; ALT, alanine aminotransferase; GGT, gamma-glutamyl transpeptidase; INR, international normalized ratio of prothrombin time; APRI, AST to platelet ratio index; FIB-4, fibrosis index based on the four factors; GPR, GGT to platelet ratio; NLR, neutrophil to lymphocyte ratio. Sensitivity 1..8.6.4.2 FIB-4: AUC,.82; cut-off, 1.571; P value, <.1 GPR: AUC,.84; cut-off,.299; P value, <.1.2.4.6.8 1. 1-Specificity FIB4 GPR Reference Fig. 2. Receiver operating characteristic (ROC) curve analysis of FIB-4 and GPR for the evaluation of liver fibrosis comparing transient elastography (fibroscan) results in chronic hepatitis B patients. 고찰 만성간질환자에서간섬유화의정도를확인하는것은질환의진행정도를판단하는기준으로매우중요하다. 현재까지알려진기준검사로는초음파가이드간조직검사이나이는침습적이고출혈이나기타부작용의위험과반복측정의문제로널리사용되기에는어려움이있다. 본연구는비침습적인방법으로경제적이고손쉽게반복측정이가능한간섬유화정도를판단하기위한지표를개발하고자하였다. 그러나기준검사인간조직검사와여러가지혈액검사지표를비교하는것은현실적으로어려움이있어간조직검사의결과와비교적높은상관성을보여주는간탄력도검사의결과를기준으로여러가지지표들을비교분석하였다. 대표적인바이러스성간염환자를대상으로만성 B형간염환자, HBeAg 여부를고려한만성 B형간염환자및만성 C형간염환자를대상으로비침습적간섬유화진단마커를개발하고자하였다. 분석결과 B형간염환자에서는 GPR과 FIB-4 지표가의미있게도출되었 www.labmedonline.org 157

Table 5. Levels of parameters according to liver stiffness measurement in chronic HCV infected patients 고, 특별히 HBeAg 양성자에서는 FIB-4 가 HBeAg 음성자에서는 GPR 과 FIB-4 가유의하였다. 만성 C 형간염환자에서도 GPR 과 FIB-4 지표가간섬유화를판단하는의미있는지표로확인되었다. 이번연구에서는대표적인만성바이러스성간염질환인 B 형및 C 형간염바이러스감염자들을대상으로비침습적간섬유화정도 를판별하는마커를찾고자하였다. 미국간학회에서는만성 B 형간염환자의경우치료의결정은 B 형간염바이러스의 s 표면항원 (HBsAg), e 항원 (HBeAg), 바이러스 의양, 간염증정도, 간섬유화정도를고려하도록권고하고있다 [11]. FIB-4 지표는여러종류의간질환에서의그의의가보고되었 는데, 만성 B 형간염환자에서한연구에의하면, cut-off 1.6 을기 준으로진행된간섬유화정도를예측하는음성예측도가 93.2% 라 는보고가있었다 [12]. 또한다른연구에의하면 FIB-4 는만성 B 형 간염환자에서 F3-F4 수준의간섬유화는 91% 진단민감도 (AUROC:.91) 를, 보다심한 F4 수준은 88% 진단민감도 (AUROC:.93) 를보 인다고보고하였다 [13]. LSM<5.3 kpa (N=74) LSM 5.3 kpa (N=26) P value Genotype 1b/2a 37/37 17/9.176* Age (yr) 53 58.16 Male/Female 37/37 11/15.499* LSM (kpa) 4.5 1.3 <.1 AST (U/L) 36 65 <.1 ALT (U/L) 44.5 82.1 GGT (U/L) 27.5 83.5 <.1 Bilirubin (mg/dl).58.75.1 Cholesterol (mg/dl) 191.5 16.5.1 Triglyceride (mg/dl) 117.5 98.4 Platelet ( 1 9 /L) 237.5 173.5 <.1 MPV (fl) 7.25 7.9.4 INR (sec).985 1.25.5 HCV RNA 834, 1,51,.535 AST to ALT ratio.86.845.786 APRI.45 1.5 <.1 FIB-4 1.245 2.78 <.1 GPR.12.475 <.1 NLR 1.755 1.45.21 NLR/platelet.7.8.49 *Pearson s chi-square test. Abbreviations: GGT, gamma-glutamyl transferase; MPV, mean platelet volume; INR, international normalized ratio of prothrombin time; APRI, AST to platelet ratio index; FIB-4, fibrosis index based on four factors; GPR, GGT to platelet ratio; NLR, neutrophil to lymphocyte ratio. 최근에는 HBeAg 양성여부와상관없이 GPR, APRI 와 FIB-4 지 표들은간섬유화진행정도를중등도수준으로예측가능한것으로 확인되었고, 이중 GPR 이가장높은효율을보여주었다 [14]. GPR 의경우영국의 Lemoine 등 [15] 이서아프리카의 B형간염환자에서유의한간섬유화정도를예측하고자개발하였다. Lemoine 등은 GPR이서아프리카의만성 B형감염자에서 APRI와 FIB-4보다간섬유화정도를보다더정확하게보여주는것으로보고하였다. 이번연구에서 GPR cut-off.299를적용하면곡선하면적.84, 민감도 79.4%, 특이도 83.3%, 양성예측도 83.3%, 음성예측도 83.3% 를보여 Lemoine 등의연구 [15] 의 GPR cut-off.32 기준시 F-1과 F2-4를구분하는곡선하면적.8, 민감도 84%, 특이도 69%, 양성예측도 63%, 음성예측도 86% 와비교시특이도와양성예측도에서보다높은수준임을확인하였다. C형간염의경우, APRI 지표는한메타분석에의하면심한섬유화를예측하는곡선하면적이.8 정도였고, cut-off 1.을이용하면민감도, 특이도는각각 61%, 64% 정도로확인되었다 [16]. FIB-4의경우 cut-off 1.45 미만인경우심한간섬유화를선별하는음성예측도가 94.7%, 민감도는 74.3% 수준이었고, FIB-4가 3.25를상회하는경우심한간섬유화 (F3 F4) 를확인하는양성예측도가 82.1%, 특이도가 98.2% 로보고되었다 [17]. 다중로지스틱회귀분석에서는 GGT, TG, FIB-4가통계적으로 C형간염으로인한간섬유화를구별하는유의미한지표로도출되었는데간섬유화위험도의예측은 FIB-4 수치의증가가가장높았다. 그러나이번연구에서 HCV는대상자수가충분하지않다고판단된다. 기존에보고된 FIB-4의경우 AUROC.85 수준 [17] 인데이번연구에서는.816 정도로다소낮았다. 이번연구의제한점으로는첫째, 후향적자료분석의한계점, 둘째, 간조직검사대신 Fibroscan 검사를기준검사로설정하여비만환자, ALT가높은환자등간탄력도검사결과에부정확요소를배제하지못한점, 셋째, C형간염환자의경우대상자수가부족한점, 넷째, 계산지표외에 cytokeratin 18이나 Enhanced Liver Fibrosis (ELF) 검사등실제측정지표를포함하지못한점, 다섯째, 간섬유화발생기준을질환별로구분하지않고간탄력도검사결과 5.3 kpa 이상으로일괄적용하여분석한점등을언급할수있겠다. 최근 cytokeratin 18, ELF 그리고 M2BPGi 등을직접측정하여비침습적으로간섬유화정도를판별하려는노력들이이어지고있다. 이러한직접측정마커는추가비용이발생하지만진단정확도면에서계산지표등간접측정마커와비교연구는더필요한실정이다. 대표적으로, Cytokeratin 18은간세포특이적세포사멸마커로알려져있으며비침습적으로지방증 (steatosis), 염증및섬유화의정도를예측하는지표로밝혀졌다 [18]. ELF는 hyaluronic acid (HA), tissue inhibitor of matrix metalloproteinases-1 (TIMP-1), 그리고 aminoterminal propeptide of procollagen type III (P3NP) 를조합한수식으로 C형간염이주된만성간질환에서중등도이상의간섬유화를진단하는높은정확도를보여주었다 [19]. 최근에는 158 www.labmedonline.org

M2BPGi 연구가활발한데, 당단백근간의바이오마커로 Wisteria floribunda agglutinin-positive Mac-2-binding protein (WFA+-M2BP) 으로알려져있으며, 바이러스간염 [2], 만성 C형간염 [21], 비알코올성지방간 (NAFLD) [22], 원발성담관염 (primary biliary cholangitis) [23] 및자가면역간염 (autoimmune hepatitis) [24], 담도폐쇄증 (biliary atresia) [25] 등의여러가지질환에서간섬유화를예측하는지표로알려졌다. 이번연구에서 GPR이만성 B형간염환자에서는 FIB-4보다간섬유화정도를보다잘설명해주는것같았으나이번연구의전체대상자의 57% 정도가 HBeAg 음성자이었으며대상자를 HBeAg 양성여부로나누어서분석시에는 HBeAg 양성자에서 GPR이간섬유화정도를반영하는정도가보다낮았다. 그원인으로 HBeAg이음전화될때의임상적특징으로 B형간염만성화시간이 HBeAg 양성자보다일반적으로길고그에따라 GGT와혈소판수치가간섬유화를예측하기에보다더많은변수에노출될수있다는점과심하게진행된간섬유화에서의지표상의현격한차이 ( 예를들면아주심한간질환에서의정상간효소수준등의보고시 ) 등을고려해볼수있을것같다. 따라서이에대한보완추적연구가도움이되리라생각된다. 향후비침습적간섬유화진단마커개발연구와관련한추적연구가요망되며특별히최근증가하고있는비알코올성지방간환자를대상으로비침습적간섬유화및비알코올성지방염증 (non-alcoholic steatohepatitis, NASH) 질환의감별을위한비침습적진단검사개발도유용하리라판단된다. 요약 배경 : 비침습적간섬유화판별은만성간질환자들에게매우중요한이슈이다. 이번연구에서는간탄력도검사를기준으로후향적자료분석을통한비침습적간섬유화마커를개발하고자하였다. 방법 : 간탄력도검사와 B형간염바이러스핵산증폭검사를시행한 278명의만성간염환자데이터를분석하였다. 또한총 115명의 HBeAg 양성환자와 159명의 HBeAg 음성환자의데이터를각각분석하였다. 또한총 1명의만성 C형간염환자의데이터도분석하였다. 성공적인간탄력도검사수행및 gamma-glutamyl transferase (GGT) to platelet ratio (GPR), 혈소판수 (platelet count), 간전이효소 (AST, ALT), 프로트롬빈시간 (international normalized ratio, INR), 총콜레스테롤 (total cholesterol), 중성지방 (triglycerides), 빌리루빈 (bilirubin), 평균혈소판용적 (mean platelet volume, MPV), AST to platelet ratio index (APRI), fibrosis index based on four factors (FIB-4), 중성구대비림프구비율 (neutrophil to lymphocyte ratio, NLR) 지표와 NLR 대비혈소판수비율분석을통하여간섬유화진단마커를찾기위한분석을진행하였다. 결과 : 만성 B형간염환자군에서는 GPR (OR = 9.1, P =.11) 과 FIB-4 (OR=2.3, P =.1) 간섬유화의위험도증가와상관관계가높았다. HBeAg 양성자에서는 FIB-4 (OR= 6.4, P =.5) 가 HBeAg 음성자에서는 FIB-4 (OR=2.371, P =.15) 와 GPR (OR =33.78, P =.3) 이간섬유화의위험도를의미있게반영하였다. C형간염환자에서는다중로지스틱회귀분석에서는 GGT (OR =1.33, 95% CI: 1.12 1.55, P =.2), 중성지방 (OR =-.99, 95% CI:.981.999, P =.38) 및 FIB-4 (OR=3.499, 95% CI: 1.444 8.48, P =.6) 가통계적으로유의하게도출되었다. ROC 커브분석에서는 FIB-4가.816 (P <.1), GPR이.849 (P <.1) 의곡선하면적 (area under the curve) 을보여주었다. 결론 : FIB-4와 GPR은만성 B형간염과 C형간염환자의간섬유화정도를판별하는유용한마커로생각된다. 그러나임상적으로적용하기위하여보다잘설계된전향적연구를통한비침습적인혈액마커에대한검증이필요하다고판단된다. 이해관계 저자들은본연구와관련하여어떠한이해관계도없음을밝힙니다. 감사의글 본연구는대한진단면역학회 217년학술연구비지원으로수행되었습니다. REFERENCES 1. Bravo AA, Sheth SG, Chopra S. Liver biopsy. N Engl J Med 21;344:495-5. 2. Coco B, Oliveri F, Maina AM, Ciccorossi P, Sacco R, Colombatto P, et al. Transient elastography: a new surrogate marker of liver fibrosis influenced by major changes of transaminases. J Viral Hepat 27;14: 36-9. 3. Colombo S, Belloli L, Buonocore M, Jamoletti C, Zaccanelli M, Badia E, et al. True normal liver stiffness measurement (LSM) and its determinants. Hepatology 29;5:741A-2A. 4. Foucher J, Chanteloup E, Vergniol J, Castéra L, Le Bail B, Adhoute X, et al. Diagnosis of cirrhosis by transient elastography (FibroScan): a prospective study. Gut 26;55:43-8. 5. Friedrich Rust M, Ong MF, Martens S, Sarrazin C, Bojunga J, Zeuzem S, et al. Performance of transient elastography for the staging of liver www.labmedonline.org 159

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