类风湿关节炎患者应用雷公藤致药物性肝损伤的临床特征与预后

摘要/Abstract

摘要： 目的探讨类风湿关节炎(RA)患者应用雷公藤所致药物性肝损伤(DILI)的临床分型特征及预后。方法纳入2022年4月至2025年6月联勤保障部队904医院应用雷公藤治疗RA后发生DILI患者96例,其中肝细胞型45例、胆汁淤积型35例、混合型16例。比较不同临床分型患者的起病特征、基线临床资料、实验室检查结果、治疗过程及预后结局。结果肝细胞型患者起病时间最短为28(18,41)d,急性起病比例最高(62.2%);而胆汁淤积型和混合型起病时间分别为56(38,82)d 和 43(29,65)d,合并黄疸比例显著升高,为60.0%和56.3%(均P<0.05)。肝细胞型ALT水平显著升高为612(388,945)U/L;胆汁淤积型和混合型ALP分别为386(291,524)U/L、312(236,418)U/L,TBil分别为68.4(45.2,103.7)μmol/L、52.1(34.6,78.9)μmol/L,明显高于肝细胞型(均P<0.05)。在治疗过程中,胆汁淤积型和混合型熊去氧胆酸使用率(62.9%、50.0%)、糖皮质激素使用率(42.9%、43.8%)、住院率(60.0%、50.0%)及住院时间14(10,19)d、12(9,16)d均显著高于肝细胞型(P<0.05)。在预后方面,肝细胞型肝功能完全恢复率最高(91.1%),ALT正常化时间最短,为46(32,68)d;胆汁淤积型和混合型延迟恢复发生率分别为51.4%和43.8%,慢性DILI发生率分别为20.0%和18.8%。结论 RA患者应用雷公藤所致DILI具有明显的临床分型异质性,胆汁淤积型和混合型患者恢复较慢、预后相对较差。DILI临床分型有助于雷公藤相关肝损伤的早期风险评估及个体化管理。

关键词: 类风湿关节炎, 药物性肝损伤, 雷公藤, 临床分型

Abstract: Objective To investigate the clinical phenotype characteristics and prognostic differences of drug-induced liver injury (DILI) caused by Tripterygium wilfordii in patients with rheumatoid arthritis (RA), and to provide evidence for early identification and risk stratification management of Tripterygium wilfordii-related liver injury. Methods Patients with RA who developed DILI after treatment with Tripterygium wilfordii were enrolled. Based on liver biochemical parameters at onset, the R ratio was calculated and patients were classified into hepatocellular, cholestatic, and mixed DILI phenotypes. Onset characteristics, baseline clinical data, laboratory findings, treatment course, and prognostic outcomes were compared among the different phenotypes. Results A total of 96 patients with Tripterygium wilfordii–associated drug-induced liver injury (DILI) were included, comprising 45 cases of hepatocellular type, 35 cases of cholestatic type, and 16 cases of mixed type. Patients with hepatocellular DILI had the shortest time to onset[28 (18, 41) days] and the highest proportion of acute onset (62.2%), whereas those with cholestatic and mixed DILI showed significantly delayed onset[56 (38, 82) days and 43 (29, 65) days, respectively] and markedly higher rates of concomitant jaundice (60.0% and 56.3%, respectively; all P<0.05). Laboratory findings revealed markedly elevated ALT levels in the hepatocellular group[612 (388, 945) U/L], while ALp[386 (291, 524) U/L and 312 (236, 418) U/L] and total bilirubin (TBil)[68.4 (45.2, 103.7) μmol/L and 52.1 (34.6, 78.9) μmol/L] levels were significantly higher in the cholestatic and mixed groups than in the hepatocellular group (all P<0.05). During treatment, the rates of ursodeoxycholic acid use (62.9% and 50.0%), glucocorticoid use(42.9% and 43.8%), hospitalization (60.0% and 50.0%), and length of hospital stay[14 (10, 19) days and 12 (9, 16) days] were all significantly higher in the cholestatic and mixed groups compared with the hepatocellular group (P<0.05). In terms of prognosis, the hepatocellular group showed the highest rate of complete liver function recovery (91.1%) and the shortest ALT normalization time[46 (32, 68) days], whereas delayed recovery occurred in 51.4% and 43.8% of patients in the cholestatic and mixed groups, respectively, and chronic DILI developed in 20.0% and 18.8% of patients, respectively (P<0.05 or a trend toward difference). Conclusion DILI caused by Tripterygium wilfordii in patients with RA exhibits marked heterogeneity across clinical phenotypes. Significant differences exist among DILI phenotypes in onset patterns, clinical course, and prognostic outcomes, with cholestatic and mixed phenotypes associated with slower recovery and poorer prognosis. Clinical phenotyping of DILI is helpful for early risk assessment and individualized management of Tripterygium wilfordii-related liver injury.

Key words: Rheumatoid arthritis, Drug-induced liver injury, Tripterygium wilfordii, Clinical phenotype

尤虹, 钱先中, 孙舒, 胡艳蓉, 陆佳赟. 类风湿关节炎患者应用雷公藤致药物性肝损伤的临床特征与预后[J]. 肝脏, 2026, 31(6): 896-899.

You Hong, Qian Xianzhong, Sun Shu, Hu Yanrong, Lu Jiayun. Clinical characteristics and prognosis of drug-induced liver injury caused by tripterygium wilfordii in patients with rheumatoid arthritis[J]. Chinese Hepatolgy, 2026, 31(6): 896-899.

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