摘要：

目的 探讨血清肌酶谱在不同类型肌肉病与病毒性肝炎之间的表达差异。方法 选择2018 年 1-9 月确诊的 578 例肌肉病和 51 例病毒性肝炎患者，检测其血清肌酶谱［肌酸激酶（CK）、乳酸脱氢酶（LDH）、天冬氨酸转氨酶（AST）、丙氨酸转氨酶（ALT）、AST/ALT 比值］变化，并比较不同类型肌肉病，以及肌肉病与病毒性肝炎患者血清肌酶谱表达的差异性。结果 不同类型肌肉病患者 CK（χ² =107.710，P = 0.000）、LDH（χ² = 36.382，P = 0.000）、AST（χ² = 47.608，P = 0.000）和 ALT（χ² = 31.722，P = 0.000）差异均有统计学意义，其中，肌营养不良症患者 CK 和 LDH 高于炎性肌肉病（Z = 9.297，P = 0.000；Z = 2.475，P = 0.040）和代谢性肌肉病（Z = 6.765，P = 0.000；Z = 5.983，P = 0.000），AST 高于代谢性肌肉病（Z = -5.363，P = 0.000），ALT 高于炎性肌肉病（Z = 5.619，P = 0.000）；代谢性肌肉病患者 LDH 亦高于炎性肌肉病（Z = 4.590，P = 0.000）。肌肉病与病毒性肝炎血清肌酶谱比较，前者 CK（Z = -10.975，P = 0.000）、LDH（Z = -6.967，P = 0.000）和 AST/ALT 比值（Z = -5.605，P = 0.000）升高、ALT 降低（Z = 3.949，P = 0.000）；ROC 曲线提示，CK、LDH、AST、ALT、AST/ALT 比值曲线下面积分别为 0.943（95%CI：0.919 ~ 0.966，P = 0.000）、0.818（95%CI：0.756 ~ 0.881，P = 0.000）、0.446（95%CI：0.350 ~ 0.542，P = 0.217）、0.323（95%CI： 0.224 ~ 0.422，P = 0.000）、0.745（95%CI：0.671 ~ 0.819，P = 0.000），其中 CK 和 AST/ALT 比值鉴别诊断肌肉病与病毒性肝炎的灵敏度为 0.880 和 0.512、特异度 0.961 和 0.882、最大 Youden 指数 0.841 和 0.394。结论 不同类型肌肉病患者血清肌酶谱表达变化存在一定规律性，可为肌肉病临床分型提供线索。AST/ALT比值对鉴别诊断肌肉病与病毒性肝炎具有一定提示意义，不明原因肝酶谱升高者应测定血清 CK。

关键词:  肌疾病, 肌酸激酶, 乳酸脱氢酶类, 天冬氨酸氨基转移酶类, 丙氨酸转氨酸, 诊断, 鉴别

Abstract:

Objective To explore the expression differences of serum muscle enzymes among different types of myopathies and viral hepatitis.  Methods  This study enrolled 578 patients with myopathies and 51 patients with viral hepatitis from January to September 2018. Serum muscle enzymes [creatine kinase (CK), lactic dehydrogenase (LDH), aspartate aminotransferase (AST), alanine aminotransferase (ALT) and AST/ALT ratio] were detected in all patients, and the expression differences of serum muscle enzymes were compared among different types of myopathies, and between myopathies and viral hepatitis.  Results  In myopathy patients, there were significant differences on the values of CK (χ² =107.710, P = 0.000), LDH (χ² = 36.832, P = 0.000), AST (χ² = 47.608, P = 0.000) and ALT (χ² = 31.722, P = 0.000) among different types of myopathies. Patients with muscular dystrophy had significantly higher expression of CK and LDH than inflammatory myopathy (Z = 9.297, P = 0.000; Z = 2.475, P = 0.040) and metabolic myopathy (Z = 6.765, P = 0.000; Z = 5.983, P = 0.000), higher expression of AST than metabolic myopathy (Z = -5.363, P = 0.000), and higher ALT than inflammatory myopathy (Z = 5.619, P = 0.000). The value of LDH in metabolic myopathy patients was significantly higher than that in inflammatory myopathy (Z = 4.590, P = 0.000). Compared with patients with viral hepatitis, myopathy patients had significantly increased CK (Z = -10.975, P = 0.000), LDH (Z = -6.967, P = 0.000) and AST/ALT ratio (Z = -5.605, P = 0.000), and decreased ALT (Z = 3.949, P = 0.000). Receiver operating characteristic (ROC) curve showed the area under the curve (AUC) of CK, LDH, AST, ALT and AST/ALT ratio were 0.943 (95% CI: 0.919-0.966, P = 0.000), 0.818 (95%CI: 0.756-0.881, P = 0.000), 0.446 (95%CI: 0.350-0.542, P = 0.217), 0.323 (95% CI: 0.224-0.422, P = 0.000), 0.745 (95% CI: 0.671-0.819, P = 0.000), respectively. In the differential diagnostic test between myopathies and viral hepatitis, the sensitivity of CK and ratio of AST/ ALT was 0.880 and 0.512, the specificity of which was 0.961 and 0.882, the maximum Youden index of which was 0.841 and 0.394. Conclusions The serum muscle enzymes spectrum in different types of myopathies were different, but there existed some rules, which could provide clues for clinical classification of myopathies. The ratio of AST/ALT had suggestive values in the differential diagnoses between myopathies and viral hepatitis. For patients with increased transaminase of unknown reasons, serum CK should be detected.

Key words: Muscular diseases, Creatine kinase, Lactate dehydrogenases, Aspartate aminotransferases, Alanine transaminase, Diagnosis, differential