Резюме
Іванова Л.М., Налапко К.К., Сидоренко Ю.В., Холіна О.А., Васильєва В.Л. Стан клітинної, гуморальної ланок імунітету та цитокінового профілю крові у хворих на неалкогольний стеатогепатит у сполученні з хронічним бронхітом та ожирінням.
При НАСГ у сполученні з ХБ та ожирінням мав місце вторинний імунодефіцит, переважно по відносному Т-супресорному варіанту, який супроводжувався зростанням вмісту ЦІК за рахунок найбільш патогенних фракцій та превалюванням у сироватці крові прозапальних властивостей  над протизапальними.
Ключові слова: неалкогольний стеатогепатит, хронічний бронхіт,  ожиріння, імунітет, цитокіновий профіль крові.

Резюме
Иванова Л.Н., Налапко К.К., Сидоренко Ю.В., Холина Е.А., Всильева В.Л. Состояние клеточного, гуморального звеньев иммунитета и цитокинового профиля крови у больных с неалкогольным стеатогепатитом в сочетании с хроническим бронхитом и ожирением.
При НАСГ в сочетании с ХБ и ожирением имел место вторичный иммунодефицит, преимущественно по относительному Т-супрессорному варианту, который сопровождался повышением содержания ЦИК за счет наиболее патогенних фракций и превалированием в сыворотке крови провоспалительных  свойств над противовоспалительными.
Ключевые слова: неалкогольный стеатогепатит,  хронический бронхит, ожирение, иммунитет, цитокиновый профиль крови.

Summary
Ivanova L.M., Nalapko K.K., Sidorenko Yu.V., Cholina O.A., Vasilieva V.L. State of cellular, humoral immunity and blood cytokine profile in patients with nonalcoholic steatohepatitis in combination with chronic bronchitis and obesity.
In patients with nonalcoholic steatohepatitis in combination with chronic bronchitis and obesity secondary immunodeficiency occurred, mainly by the relative T-suppressor way, which was associated with increased circulated immune complexes by most pathogenic fractions and the prevalence in serum pro-inflammatory properties.
Key words: nonalcoholic steatohepatitis, chronic bronchitis, obesity, immunity, cytokine profile of blood.

Рецензент: д.мед.н., проф. І.В. Лоскутова

УДК 616.36 – 002 – 003.826 + 616.233 – 002 – 036.12

ДЗ «Луганський державний медичний університет»

ГЗ «Луганский государственный медицинский университет»

State Establishment "Lugansk State Medical University"

propedevtika2011@yandex.ru, ksenia-777@ukr.net, siderman@ukr.net, e-holina@mail.ru

Introduction. The structure of disease plays a significant role combined pathology that occurs in 25.6 % - 41.7 % of cases, negatively affecting the clinical course and prognosis of disease [ 2, 6 ]. According to epidemiological studies, incidence of nonalcoholic steatohepatitis (NASH) is an average of 23%, including in Ukraine over the past 5 years, the incidence of steatohepatitis increased by 76.5 %, and the prevalence increased by 2.2 times [ 3, 5, 9, 13 ]. Alimentary obesity as an independent metabolic diseases associated with hyperinsulinemia, insulin resistance, and adipocytokins that are expressed in adipose tissue, may have both pro- and anti-inflammatory effects [1, 2, 3]. However, one of the diseases, which are often combined NASH is a chronic bronchitis ( CB), the prevalence of which ranges from 10 to 20 % [ 6, 11 ]. In this case, both the stability and destabilization in hepatobiliary and respiratory systems essential role to play in cellular and humoral immunity [4, 8], cytokine production [7, 12].

Relationship of academic programs, plans, themes. The research was conducted in accordance with the basic plan of scientific research "Lugansk State Medical University", and is a fragment of threads Chair of Internal Medicine, " Medical rehabilitation of patients with combined pathology » (№ state registration 0109U004608).
Objective: To determine the immune pathogenesis of nonalcoholic steatohepatitis chains, coupled with chronic bronchitis and obesity.

Materials and methods

The study involved 120 patients with NASH in conjunction with HB and obesity (women 69 - 62 % Men - 45 - 38% ), aged 23 to 75 years with a duration of comorbidity between 1 and 12 years. To determine the reference standards were examined 35 healthy individuals, age and sex of which correspond to similar values of patients. Of the patients studied was formed two groups randomized by age, sex, duration and frequency of exacerbations NASH : main (68 persons) and comparison ( 52 people).

Verification NASH conducted in accordance with the requirements of the Order of the Ministry of Health of Ukraine from 13.06.2005, № 271 "On approval of the protocols of medical care in" Gastroenterology ".

Verification of the diagnosis of chronic bronchitis ( according to ICD- 10 code J 41.0) was carried out in accordance with the requirements of the Order of the Ministry of Health of Ukraine from 19.03.2007, № 128 "On approval of clinical protocols of care in the specialty" Pulmonology ". Anthropometric study included height, body weight, waist circumference and volume thighs. To assess body weight was used body mass index (BMI ) - Quetelet index. The study included patients only with alimentary- constitutional obesity type ( ICD-10 code F 66.0 ).

Immunological studies included the study of indicators of cellular and humoral immunity, the cytokine profile of blood ( GIC). State of cellular immunity - the number of the total population of T -(CD3 +) and B lymphocytes (CD22 +), T- helper/inductors subpopulations (CD4 +) and T-supressors/killers (CD8 +) in peripheral blood cytotoxic test using commercial monoclonal antibodies ( mAbs ) classes CD3 +, CD4 +, CD8 +, CD22 + production SPC " MedByoSpektr " (Russia, Moscow). Calculated in immunoregulatory index CD4/CD8, which was interpreted as the ratio of T- helper lymphocytes and suppressor activity (Th / Ts). Evaluation revealed shifts undertaken by " immunological compass " [10 ]. The functional activity of T lymphocytes was studied by reaction of blast transformation of lymphocytes ( RBTL ) when setting it micromethod. The concentration of circulating immune complexes ( CIC ) in serum was studied by precipitation in a solution of polyethylene glycol (PEG) with a molecular weight of 6000 D. The molecular structure of CIC with the definition of large- (19 > S), medium -(11S-19S) and small molecular (<11S ) fractions by differential precipitation in 2.0%, 3.5 % and 6.0 % solutions of PEG.

The level of cytokines (CC ) (TNF-α, IL-lβ and IL- 4 ) in serum were determined by ELISA with the use of certified in Ukraine test kits produced by " Protein contour" (Russia, St. Petersburg) according to the instructions of the manufacturer.
Statistical analysis of the results was carried out at the Computing Center of the East- Ukrainian National University. Dal using multivariate analysis of variance with the use of licensed software packages Microsoft Office 97, Microsoft Exel Stadia 6.1/prof and Statistica.

Obtained results and discussion

Analysis of immunological examination of patients with combined pathology revealed that in acute NASH have been the likely shifts from immunological parameters cellular link, and marked T lymphopenia, imbalance subpopulation composition of T lymphocytes mainly by reducing the number of circulating T- helper/inductors (CD4 +), decrease of immunoregulatory index CD4/CD8 (Th / Ts), and the functional activity of T lymphocytes according RBTL.

The absolute number of CD3 +- lymphocytes was reduced by an average of 1.6 -fold ( p < 0.01). In the study group the level of CD3 +- cells was on average 46,2 ± 1,3%, in comparison group - 45,9 ± 1,2%, that was reduced to 1.51 and 1.52 times respectively to normal.

The number of CD4 +- cells in the examined patients decreased on average 1.4 times (31,5 ± 0,8%; p < 0.01). The number of CD4 +- lymphocytes ( T- helper/inductors) in the comparison had an average of 1.43 times lower than normal relative calculation and 1.53 times - in absolute (p < 0.01). In the study group patients relative number of T-helper (CD4 +) was 1.43 times lower than normal absolute - to 1.53 -fold ( p < 0.001). Thus, in the study group noted fewer T-helper/inductors as relative, so also in absolute terms.

The level of lymphocytes with CD8 + phenotypes in most surveyed in NASH in a combination of cotton and obesity decreased, although in some patients was lower limits of normal. Thus, the content of CD8 +- cells ( T-suppressors/killers) in relative terms amounted to an average of 18,6 ± 0,6%, ie the multiplicity of regulations relative decrease was 1.2 times. Number T-suppressors/killers examined in the main group and the comparison group decreased to 1.21 and 1.19 times respectively. The absolute number of CD8 +- cells was moderately reduced in both groups studied (p < 0.05). CD4/CD8 immunoregulatory index was reduced by an average of 1.2 times (1,69 ± 0,02 at a rate of 2,04 ± 0,03; p < 0.01). The ratio of cells with helper and suppressor activity (CD4/CD8) in the intervention group were less than normal at 1.18 times ( p < 0.01 ) in the comparison group - to 1.19 -fold ( p < 0.001).

The relative number of CD22 +- lymphocytes ( total population of B cells ) in patients with moderate comorbidity decreased significantly in relative and in absolute terms relative to the norm. The average level of CD22 +- cells was 19,6 ± 1,4% ( at a rate of 21,6 ± 1,3%; p> 0.05 ). The absolute number of B cells in the examined patients had moderately reduced ( p < 0.05). The number of B cells in patients of the group amounted to 19,3 ± 1,8%, in comparison group - 20,0 ± 1,1% ( p> 0.05 ).

In patients with comorbidity observed inhibition of the functional activity of T lymphocytes according RBTL with PHA, the rate of which declined by an average of 1.4 times to 49,6 ± 1,6% at a rate of 69,5 ± 2,3% ( p < 0.01) : the study group at 1.38 times in comparison group - 1.39 -fold ( p < 0.001).

In patients with NASH in combination with cotton and obese overall CIC in serum was increased in the intervention group patients 1.8 times (3,42 ± 0,03 g / l ) in the comparison group - 1, 77 times ( 3,35 ± 0,05 g / l) (p < 0.01). In the study of the molecular structure of CIC set to grow mainly due to toxigenic medium and small molecular fractions. Content of medium molecular fractions were patients of the main group at 2.65 times higher than normal (1,62 ± 0,02 g / l ) in the comparison group - to 2.57 times (1,56 ± 0,03 g / l), while the concentration small molecular fractions constituted 1,2 ± 0,03 g / l and 1,0 ± 0,04 g / l, that was 2.63 and 2.41 times higher than normal (p < 0.001) (Table 2). Statistically significant differences in this indicator in patients of group and comparison group were observed (P> 0.05).

Література

1. Грузєва Т.С. Ожиріння як глобальна проблема громадського здоров’я / Т.С. Грузєва, Г.В. Іншакова // Главный врач. - 2008. - № 11. - C. 34-36.
2. Драпкина О.М. Неалкогольная жировая болезнь печени и метаболический синдром / О.М. Драпкина // Справочник поликлинического врача. 2008. - № 3. - С. 71–74.
3. Драпкина О.М., Смирин В.И., Ивашкин В.Т. Неалкогольная жировая болезнь печени – современный взгляд на проблему / О.М. Драпкина, В.И. Смирин, В.Т. Ивашкин // Лечащий врач. - 2010. - Т. 5, № 5. - С. 57–61.
4. Єлизарова Т.О. Стан клітинної ланки імунітету у хворих на неалкогольний стеатогепатит / Т.О. Єлизарова, Л.В. Кузнецова // Український медичний альманах. – 2010. – Т. 13, № 5. – С. 74-76.
5. Звягинцева Т.Д. Современные подходы к лечению неалкогольного стеатогепатита / Т.Д. Звягинцева, А.И. Чернобай // Сучасна гастроентерологія. – 2009. – № 3 (47). – С. 35-42.
6. Маев И.В. Состояние органов пищеварения при хроническом бронхите, бронхиальной астме, эмфиземе легких / И.В. Маев, Л.П. Воробьев, Г.А. Бусарова // Пульмонология. – 2002. – № 4. – С. 85-92.
7. Маммаев С.Н. Цитокиновая система при неалкогольном стеатогепатите / С.Н. Маммаев, Н.В. Багомедова, П.О. Богомолов // Рос. журн. гастроэнтерол. гепатол. колопроктол. – 2007. – Т. 17, № 4. – С. 30–35.
8. Типовые реакции иммунной системы при различных патологических процессах / А.М. Земсков, М.А. Земсков, В.И. Золодедов [и др.] // Журн. теоретической и практической медицины. – 2004. – Т. 2, № 1. – С. 6-12.
9. Філіппов Ю.О. Захворюваність основними хворобами органів травлення в Україні: аналітичний огляд офіційних даних Центру статистики МОЗ України / Ю.О. Філіппов, І.Ю. Скирда, Л.М. Петречук // Гастроентерологія: міжвід. збірник. – Дніпропетровськ, 2007. – Вип. 38. – С. 3-15.
10.  Фролов В.М. Использование «иммунологического компаса» для диагностики иммунных нарушений / В.М. Фролов, Н.А. Пересадин, С.Е. Казакова // Клинич. лаборат. диагностика. – 1994. – № 1. – С. 10-13.
11.  Шепеленко А.Ф. Хронический бронхит / А.Ф.Шепеленко //  Трудный пациент. – 2009. – № 3. – С. 33-38.
12.  Bruunsgaard H. Aging and proinflammatory cytokines / H. Bruunsgaard, M. Pedersen // Curr. Opin. Hematol. – 2001. – Vol. 8. – P. 131-136.
13.  Leite A.B. Risk factors for nonalcoholic steatohepatitis in cryptogenic cirrhosis / A.B. Leite, A.A. Mattos, A.Z. Mattos // Arq. Gastroenterol. – 2012. – Vol. 49 (4). – P. 245-249.