本文選題：伏立康唑 + CYP2C19��； 參考：《鄭州大學(xué)》2017年碩士論文

【摘要】：背景近幾十年來,侵襲性真菌感染的情況日益嚴(yán)峻,并伴隨著較高的病死率,是院內(nèi)感染的重要死亡原因之一。目前抗真菌藥物仍是控制侵襲性真菌感染的主要手段;伏立康唑作為第二代三唑類抗真菌藥,具有更強(qiáng)的靶點(diǎn)親和力和抗真菌活性,已被多個(gè)指南推薦為治療侵襲性曲霉菌感染的一線治療藥物。伏立康唑主要由肝臟CYP450酶系代謝,CYP2C19、CYP3A4、CYP2C9系其主要代謝酶,ABCB1是體內(nèi)主要的轉(zhuǎn)運(yùn)蛋白,且CYP2C19、CYP3A4、CYP2C9、ABCB1存在的基因多態(tài)性能夠不同程度的影響酶代謝或轉(zhuǎn)運(yùn)蛋白活性;穩(wěn)態(tài)谷濃度是伏立康唑體內(nèi)暴露劑量的評(píng)價(jià)指標(biāo),與治療效果及不良反應(yīng)密切相關(guān);目前在伏立康唑的臨床抗真菌治療中仍存在著一些問題:1.伏立康唑治療窗窄;2.伏立康唑個(gè)體差異顯著;3.伏立康唑有較嚴(yán)重的不良反應(yīng);4.伏立康唑治療費(fèi)用高。伏立康唑的臨床治療受多種遺傳因素及非遺傳因素的影響,截止現(xiàn)在,尚不能完全解釋伏立康唑個(gè)體差異的原因。當(dāng)前亟需解決的就是探究伏立康唑顯著個(gè)體差異的影響因素,從而實(shí)現(xiàn)伏立康唑的個(gè)體化用藥。目的1、監(jiān)測(cè)中國漢族血液病患者伏立康唑血清初始穩(wěn)態(tài)谷濃度[(Css)min],探討伏立康唑藥代動(dòng)力學(xué)特點(diǎn);2、通過對(duì)中國漢族血液病患者CYP2C19,CYP3A4,CYP2C9以及ABCB1基因多態(tài)性的檢測(cè),初步了解河南省人民醫(yī)院中國漢族血液病患者伏立康唑代謝酶及及ABCB1基因多態(tài)性的分布特點(diǎn);3、探討CYP2C19、CYP3A4、CYP2C9等主要代謝酶以及轉(zhuǎn)運(yùn)蛋白ABCB1的基因多態(tài)性對(duì)河南省人民醫(yī)院中國漢族血液病患者(Css)min的影響;4、探討河南省人民醫(yī)院中國漢族血液病患者臨床非遺傳因素對(duì)(Css)min的影響。方法1、篩選于2015年3月至2016年9月收住河南省人民醫(yī)院,符合2013年《血液病/惡性腫瘤患者侵襲性真菌病的診斷標(biāo)準(zhǔn)與治療原則》血液病侵襲性真菌病的診斷標(biāo)準(zhǔn),使用伏立康唑治療或預(yù)防真菌感染并接受伏立康唑血藥濃度監(jiān)測(cè)的中國漢族血液病患者進(jìn)行回顧性研究;2、采用高效液相色譜法(HPLC)監(jiān)測(cè)伏立康唑血清谷濃度,通過全血DNA提取試劑盒提取DNA,紫外/可見光分光光度計(jì)對(duì)提取DNA進(jìn)行濃度和質(zhì)量的檢測(cè),并將DNA樣本保存于-40℃冰箱中;3、采用基質(zhì)輔助激光解吸電離飛行時(shí)間質(zhì)譜(MALDI-TOF MS)技術(shù)對(duì)21個(gè)CYP2C19、CYP3A4、CYP2C9、ABCB1等的單核苷酸多態(tài)性位點(diǎn)(SNPs)進(jìn)行基因分型。PCR引物和單堿基延伸引物由Assay Designer軟件包設(shè)計(jì),檢測(cè)過程采用Mass ARRAY系統(tǒng)完成。最終結(jié)果由Mass ARRAY RT軟件系統(tǒng)實(shí)時(shí)讀取,Mass ARRAY Typer軟件系統(tǒng)完成基因分型;4、檢索河南省人民醫(yī)院電子病歷系統(tǒng),記錄入選患者人口統(tǒng)計(jì)學(xué)資料、伏立康唑用藥途徑、基礎(chǔ)疾病、合并用藥、實(shí)驗(yàn)室檢查以及SNPs分型結(jié)果和(Css)min等數(shù)據(jù)建立數(shù)據(jù)庫;5、采用SPSS19.0統(tǒng)計(jì)學(xué)軟件對(duì)數(shù)據(jù)進(jìn)行統(tǒng)計(jì)學(xué)分析,采用χ~2檢驗(yàn)對(duì)研究中21個(gè)位點(diǎn)的基因分型結(jié)果進(jìn)行Hardy-Weinberg平衡檢驗(yàn);采用SHEsis在線軟件平臺(tái)進(jìn)行連鎖不平衡分析。單因素分析采用非參數(shù)檢驗(yàn)(兩組之間采用Mann-Whitney U檢驗(yàn),三組間采用Kruskal-Wallis檢驗(yàn)),定量數(shù)據(jù)之間的相關(guān)性采用Spearman秩相關(guān)檢驗(yàn);最優(yōu)尺度回歸用于確定導(dǎo)致(Css)min變異性的影響因素,P0.05有統(tǒng)計(jì)學(xué)意義。結(jié)果1、本研究共納入86名中國漢族血液病患者,106例次(Css)min,其中確診侵襲性真菌病(Proven IFD)3例,臨床診斷侵襲性真菌病(Probable IFD)11例,擬診斷侵襲性真菌病(Possible IFD)32例以及未確定侵襲性真菌病(Undetermined IFD)40例;(Css)min變異系數(shù)達(dá)65.8%。2、本研究中21個(gè)SNPs的次等位基因頻率(Minor allele frequency,MAF)與全球MAF存在一定程度的差異性,其中rs17882687、rs12248560、rs1799853、rs2740574、rs35599367、rs10264272和rs41303343次等位基因頻率(Minor allele frequency,MAF)非常低或?yàn)?;3、CYP2C19基因多態(tài)性是(Css)min變異性的重要影響因素,其中相對(duì)于快代謝型患者,(Css)min/D在存在rs4244285或rs4986893突變的(中間代謝型或慢代謝型)患者中更高,同時(shí)(Css)min/D與年齡呈正相關(guān);4、在中間代謝型或慢代謝型患者中,年齡及rs4646437(CYP3A4)基因型是造成(Css)min/D個(gè)體間差異的影響因素;其中rs4646437的突變(CT或TT)及高年齡與較高的(Css)min/D具有相關(guān)性;在快代謝型患者中,BMI與(Css)min/D呈正相關(guān)。結(jié)論1、伏立康唑個(gè)體差異較大,(Css)min變異性顯著;2、CYP2C19基因多態(tài)性是導(dǎo)致(Css)min變異性的重要影響因素;3、除CYP2C19基因型外,rs4646437(CYP3A4)基因型、年齡、BMI等因素的影響也需要考慮進(jìn)去,特別是對(duì)于那些CYP2C19為中間代謝型或慢代謝型的漢族血液病患者。
[Abstract]:In the past few decades, invasive fungal infections have become increasingly severe, accompanied by a high mortality rate, which is one of the most important causes of death in hospital infection. Antifungal agents are still the main means of controlling invasive fungal infections. Voriconazole, as the second generation of three azole antifungal agents, has a stronger target affinity and resistance to truth. Bacterial activity has been recommended by several guidelines as a first-line treatment for invasive Aspergillus infection. Volconazole is mainly metabolized by the liver CYP450 enzyme system, CYP2C19, CYP3A4, and CYP2C9 are the main metabolic enzymes. ABCB1 is the main transporter in the body, and CYP2C19, CYP3A4, CYP2C9, and ABCB1 existing gene polymorphisms can affect enzymes in varying degrees. The activity of metabolic or transporter protein; the steady-state Valley concentration is the evaluation index of the exposure dose of voriconazole in vivo, which is closely related to the therapeutic effect and adverse reactions. There are still some problems in the clinical antifungal treatment of voriconazole: 1. the window of voriconazole is narrow, and 2. volitazol is significantly different; 3. volantiazole is more serious. 4. voriconazole is expensive. The clinical treatment of voriconazole is affected by a variety of genetic factors and non genetic factors. By now, the reasons for the individual differences in voriconazole can not be fully explained. The current urgent need to be solved is to explore the influence factors of the difference of voriconazole, so as to realize the individuals of voriconazole Objective 1 to monitor the initial steady-state Valley concentration of voriconazole in Chinese Han blood disease patients [(Css) min], to explore the pharmacokinetic characteristics of voriconazole; 2, through the detection of CYP2C19, CYP3A4, CYP2C9 and ABCB1 gene polymorphisms in Chinese Han hemopathy, a preliminary understanding of the volt of patients with hematological diseases in the Han nationality in Henan Province People's Hospital of China. The distribution characteristics of the polymorphism of the metabolic enzyme and ABCB1 gene of rirozazole; 3, to explore the effect of CYP2C19, CYP3A4, CYP2C9 and other major metabolic enzymes and transporter ABCB1 gene polymorphisms on the min of the Chinese Han hematological patients (Css) in Henan Province People's Hospital; 4, to explore the clinical non genetic factors of hematological diseases in the Han nationality of the Chinese Han nationality (C). SS) effect of min. Method 1, screening in Henan Province People's Hospital from March 2015 to September 2016, conforming to diagnostic criteria for invasive fungal disease of patients with hematological diseases / malignancies in 2013, diagnostic criteria for invasive fungal disease of hematopathy, the use of voriconazole to treat or prevent fungal infection and to receive the concentration of voriconazole in blood. The Chinese Han blood disease patients were monitored retrospectively. 2, the serum concentration of voriconazole was monitored by high performance liquid chromatography (HPLC), DNA was extracted from the whole blood DNA extraction kit and UV / visible photometer was used to detect the concentration and quality of the extracted DNA, and the DNA samples were stored in the -40 refrigerator, and the matrix supplemented by matrix supplemented. The single nucleotide polymorphic loci (SNPs) of 21 CYP2C19, CYP3A4, CYP2C9, ABCB1, and other single nucleotide polymorphic loci (SNPs) were designed by the aid of laser desorption ionization time of flight mass spectrometry (MALDI-TOF MS) technology, and the single base extension primers were designed by the Assay Designer software package. The detection process was completed by Mass ARRAY system. Real-time reading, Mass ARRAY Typer software system completed genotyping; 4, retrieving the Henan Province People's Hospital electronic medical record system, recording selected patient demographic data, voriconazole use, basic disease, combined medication, laboratory examination and SNPs typing results and (Css) Min data set up database; 5, using SPSS19.0 statistics. Statistical analysis of the data was carried out by the software. The Hardy-Weinberg balance test was carried out on the results of the genotyping of 21 loci in the study by the chi square ~2 test; the linkage disequilibrium analysis was carried out by the SHEsis online software platform. The single factor analysis used the non parametric test (two groups using Mann-Whitney U test and three groups using Kruskal-Wallis test. Spearman rank correlation test was used to determine the correlation between quantitative data. The optimal scaling regression was used to determine the factors affecting (Css) min variability, and P0.05 had statistical significance. Results 1, 86 Chinese Han hematological patients were included in this study, 106 cases (Css) min, among which 3 cases of invasive fungal disease (Proven IFD) were diagnosed, and the clinical diagnosis was invasive. 11 cases of Probable IFD, 32 cases of invasive fungal disease (Possible IFD) and 40 cases of undetermined invasive mycosis (Undetermined IFD); (Css) the coefficient of variation of Min is 65.8%.2. The secondary allele frequency of 21 SNPs (Minor allele) in this study has a certain degree of difference from that in the world. Rs12248560, rs1799853, rs2740574, rs35599367, rs10264272, and rs41303343 secondary alleles (Minor allele frequency, MAF) are very low or 0; 3, CYP2C19 gene polymorphism is an important factor in the variability of (Css). The patients with slow metabolic type were higher, and (Css) min/D was positively correlated with age; 4 in intermediate or slow metabolic patients, age and rs4646437 (CYP3A4) genotypes were the factors contributing to the difference among individuals of (Css) min/D; the mutation of rs4646437 (CT or TT) and higher age and higher (Css) min/D were related; in fast metabolic patients Among those, BMI was positively correlated with (Css) min/D. Conclusion 1, the individual differences in voriconazole, (Css) min variability, are significant; 2, CYP2C19 gene polymorphism is an important factor leading to (Css) min variability; 3, besides the CYP2C19 genotype, the influence of rs4646437 (CYP3A4) genotypes, age, BMI and other factors should also be taken into consideration, especially for those The 19 is the middle metabolism or slow metabolism Han blood disease patients.
【學(xué)位授予單位】：鄭州大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R96
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本文編號(hào)：2044915