本文選題：原發(fā)性干燥綜合征 + 膜性腎病��； 參考：《北京協(xié)和醫(yī)學(xué)院》2015年博士論文

【摘要】：研究背景：原發(fā)性干燥綜合征(primarySjogren Syndrome, pSS)是一種多器官受累的自身免疫病,其腎臟受累常見表現(xiàn)為間質(zhì)性腎炎和腎小管酸中毒。關(guān)于pSS腎小球病變臨床病理特征的報道較少。pSS腎臟受累的機制并不明確,既往認為與局部淋巴細胞浸潤、T細胞亞群失調(diào)及自身抗體形成相關(guān),近年來認識到異位生發(fā)中心形成和上皮細胞抗原呈遞可能是pSS臟器炎癥損傷的關(guān)鍵環(huán)節(jié),傳統(tǒng)認為只表達于專職抗原呈遞細胞的共刺激分子B7-1(又稱CD80),在病理狀態(tài)下亦可表達于腎小管上皮細胞和腎小球足細胞,故可能是連接pSS管-球損傷的橋梁。小管損傷介導(dǎo)小球損傷的現(xiàn)象存在于Heymann'腎炎動物模型中,其所代表的膜性腎病(membranous nephropathy, MN)發(fā)病機制主要是由針對腎小球足細胞的特異性自身抗體在局部沉積,但在人體內(nèi)尚不清楚該自身抗體是如何產(chǎn)生的。故本研究總結(jié)了北京協(xié)和醫(yī)院近20年來原發(fā)性干燥綜合征合并膜性腎病(pSS-MN)患者的臨床病理特點,觀察腎臟間質(zhì)小管和腎小球異位生發(fā)中心形成及抗原呈遞分子表達特點,試圖探尋管-球共同損傷機制,尋找有可能影響其臨床預(yù)后的相關(guān)特點,為進一步研究其發(fā)病機制和潛在的干預(yù)措施提供一些線索。研究目的：1.回顧性觀察pSS-MN患者的臨床病理特點、治療及轉(zhuǎn)歸,初步分析影響其臨床和預(yù)后的相關(guān)因素;2.評價pSS-N MN病例腎間質(zhì)淋巴細胞浸潤及異位生發(fā)中心形成情況,初步觀察其淋巴細胞成分,分析其與臨床指標及預(yù)后的關(guān)聯(lián)性；3.觀察pSS-MN病例腎臟局部抗原呈遞分子B7-1及IL-17通路表達情況,觀察二者與臨床病理及預(yù)后的關(guān)聯(lián)性。研究方法：回顧性納入從1993年1月至2014年12月間在北京協(xié)和醫(yī)院住院患者中選出經(jīng)腎活檢確診,臨床資料完整的pSS-MN病例,收集其臨床、病理及隨訪資料,評價干燥綜合征活動性；定義血肌酐升高大于50%、終末期腎病或死亡為主要終點事件,定義蛋白尿緩解為次要終點事件。對腎小球硬化、腎小管損傷及腎間質(zhì)纖維化半定量分析。行CD21(生發(fā)中心樹突細胞標記)免疫組化染色,評價間質(zhì)淋巴細胞浸潤分級和異位生發(fā)中心形成,行CD3(T細胞標記)、Foxp3(Treg細胞標記)及IL-17(Th17細胞標記)免疫組化或免疫熒光染色,初步觀察生發(fā)中心細胞成分,并分析上述資料與臨床病理及預(yù)后的關(guān)聯(lián)性。行B7-1、IL-17A和IL-17RD(IL-17受體)免疫組化染色,觀察其在間質(zhì)浸潤的炎癥細胞、小管上皮細胞和足細胞的表達情況,并分析其表達水平與臨床病理和預(yù)后的關(guān)聯(lián)性。統(tǒng)計方法：連續(xù)變量以均值±標準差的形式表示,計數(shù)資料以構(gòu)成比表示。統(tǒng)計軟件為SPSS 19.0軟件(IBM,USA)。主要統(tǒng)計方法包括t檢驗和秩和檢驗、ANOVA、Fisher精確檢驗、單因素相關(guān)分析和Kaplan-Meier生存分析等。研究結(jié)果：1. pSS-MN病例的臨床病理特點共有42例pSS-MN患者納入本研究,占同期行腎活檢pSS病例(154例)的27.2%,pSS合并腎小球疾病病例(94例)的44.6%。臨床特點：以女性為主(76.2%),平均年齡52.3±19.0歲；發(fā)病順序以腎外pSS發(fā)病在前為主(50.0%),尚有部分患者無明顯pSS癥狀(31.0%)。臨床主要表現(xiàn)為腎病綜合征(85.7%),多伴鏡下血尿(81.0%),腎活檢時24小時尿蛋白4.6±3.1g/24h,血清白蛋白26.5±7.3g/L,eGFR 92.8±26.3 ml/min。26.8%患者伴血清IgG升高,20.0%患者伴血清C3或C4補體水平減低。9例患者(21.4%)合并慢性甲狀腺炎,該組患者血清IgG水平顯著高于其他患者(28.6±6.9g/Lvs.19.8±7.3g/L,p0.001)。15例患者進行了血清抗PLA2R抗體檢測,其中陽性8例(53.3%),陰性7例(46.7%)。病理特點：18例(42.9%)為不典型MN,以系膜區(qū)增生、電子致密物沉積或Clq陽性為特點；免疫熒光C3陽性者43.9%,C1q陽性者34.1%;其中20例患者進行了IgG亞型免疫熒光染色,以IgG4陽性為主(95%),其次為IgG1(55.0%)、IgG3(50.0%)和IgG2 (0%).治療隨訪情況：97.6%的患者接受了免疫抑制治療,包括足量激素聯(lián)合環(huán)磷酰胺(54.8%)、霉酚酸酯或雷公藤多甙(7.1%),半量激素聯(lián)合鈣調(diào)蛋白磷酸酶抑制劑(19.0%),單用足量激素(14.3%)。25例患者隨訪時間大于或等于6個月,其平均隨訪時間39.0±49.5個月,中位隨訪時間24個月。其中52%患者腎病綜合征完全或部分緩解；76.0%患者腎功能穩(wěn)定,16%患者肌酐輕度升高或波動,僅2例(8%)患者出現(xiàn)腎功能進展,伴腎病綜合征未緩解或復(fù)發(fā),其中1例進展至終末期腎病。2. pSS-MN病例的腎間質(zhì)淋巴細胞浸潤及異位生發(fā)中心形成35例pSS-MN患者完成CD21染色并進行淋巴細胞浸潤程度分級,GO(無)、G1(少量)、G2(大量)和G3(異位生發(fā)中心樣結(jié)構(gòu)形成)比例分別為5.7%、34.3%、28.6%和31.4%。其中11例G3級患者鏡下可見腎間質(zhì)密集灶性淋巴細胞浸潤,CD21染色陽性呈典型樹突細胞網(wǎng)結(jié)構(gòu),其中7例生發(fā)中心緊鄰或包繞腎小球。間質(zhì)淋巴細胞浸潤分級與小球硬化指數(shù)正相關(guān)(p=0.007),嚴重浸潤組(G2-G3)較輕微浸潤組(GO-G1)eGFR水平臨界偏低(85.7±26.7ml/min vs.100.6±23.2ml/min, p=0.068)。對臨床差異較大的兩例病例異位生發(fā)中心T細胞及亞群的染色觀察提示,不同病例生發(fā)中心成分具有差異。3. pSS-MN病例的B7-1和IL-17通路表達情況pSS-MN患者存在B7-1高表達,顯著高于輕微病變組,主要表達于腎間質(zhì)和小管上皮,極少見于腎小球內(nèi),但圍繞腎小球表達常見；B7-1表達水平與活檢時24小時尿蛋白和腎功能等臨床指標無顯著相關(guān)性,但在腎病綜合征未緩解組顯著高于緩解組(p=0.044)。腎臟局部IL-17表達升高且程度與B7-1水平正相關(guān)(p=0.048)；可觀察到pSS-MN患者小管和小球IL-17RD共表達。結(jié)論：在本研究條件下觀察到：1.pSS合并腎小球病變以MN最多見,近半數(shù)患者病理上表現(xiàn)為不典型膜性腎病,同時近半數(shù)患者血清抗PLA2R抗體陰性,但二者之間無顯著相關(guān)性。2. pSS-MN患者腎間質(zhì)伴有不同程度的淋巴細胞浸潤,近1/3伴異位生發(fā)中心樣結(jié)構(gòu)形成,淋巴細胞浸潤嚴重程度與腎功能、腎小球硬化相關(guān)；3.pSS-MN腎臟局部B7-1表達水平顯著升高,且與腎病綜合征預(yù)后相關(guān)性好；腎臟局部IL-17與B7-1表達水平正相關(guān),IL-17可能與IL-RD共同介導(dǎo)了局部B7-1的表達和球-管損傷。
[Abstract]:Background: primarySjogren Syndrome (pSS) is a kind of autoimmune disease with multiple organ involvement. Its renal involvement is often manifested by interstitial nephritis and renal tubular acidosis. The clinicopathological features of pSS glomerulopathology are reported less than the mechanism of.PSS renal involvement, previously thought to be associated with local drenching. The maladjustment of T cell subsets and the formation of autoantibodies are related. In recent years, it is recognized that the formation of ectopic germinal center and epithelial antigen presentation may be the key link in the inflammatory injury of pSS organs. The common stimulant molecule B7-1 (also known as CD80), which is only expressed in the specific antigen presenting cell, is also expressed in the kidney. Tubuloepithelial cells and glomerular podocytes may be a bridge connecting the pSS tube injury. The phenomenon of tubule injury mediates the damage of the small ball in the Heymann'nephritis animal model. The pathogenesis of the membranous nephropathy (membranous nephropathy, MN) is mainly caused by the specific autoantibodies to the glomerulopodocytes in the local area. However, it is not clear how the autoantibodies are produced in the human body. Therefore, the clinicopathological features of the patients with primary Sjogren syndrome combined with membranous nephropathy (pSS-MN) in the last 20 years of the Peking Union Medical College Hospital were summarized, and the characteristics of the renal tubule and the expression of the antigen presenting molecules in the ectopic glomeruli were observed. In order to find out the related characteristics that may affect the clinical prognosis of pSS-MN, it provides some clues for further research on its pathogenesis and potential intervention measures. The purpose of this study is to review the clinicopathological features, treatment and prognosis of pSS-MN patients, and to analyze the related factors that affect the clinical and prognosis of the patients; 2. The formation of renal interstitial lymphocyte infiltration and ectopic germinal center in pSS-N MN cases, preliminary observation of its lymphocyte composition, analysis of its correlation with clinical indicators and prognosis; 3. observe the expression of B7-1 and IL-17 pathway of renal local antigen presenting molecule in pSS-MN cases, observe the correlation between the two and the clinicopathology and prognosis. The clinical, pathological and follow-up data were collected from the hospitalized patients in Peking Union Medical College Hospital from January 1993 to December 2014 to evaluate the clinical, pathological and follow-up data to evaluate the activity of Sjogren syndrome. The definition of serum creatinine increased more than 50%, end-stage renal disease or death as the main terminal event, the definition of pSS-MN was defined. A semi quantitative analysis of glomerular sclerosis, renal tubule injury and renal interstitial fibrosis. Immunohistochemical staining of CD21 (germinal center dendritic cell markers), evaluation of interstitial lymphocyte infiltration classification and ectopic germinal center formation, CD3 (T cell marker), Foxp3 (Treg cell marker) and IL-17 (Th17 cell marker). Immunohistochemical or immunofluorescence staining, preliminary observation of the components of the germinal center cells, and the correlation between the above data and the clinicopathology and prognosis. Immunohistochemical staining of B7-1, IL-17A and IL-17RD (IL-17 receptor) was performed to observe the expression of the interstitial infiltration of inflammatory cells, the epithelial cells of the tubules and the podocytes, and the expression level of the cells. Correlation with clinicopathology and prognosis. Statistical methods: continuous variables are expressed in the form of mean mean standard deviation, counting data are represented by the constituent ratio. The statistical software is SPSS 19 software (IBM, USA). The main statistical methods include t test and rank sum test, ANOVA, Fisher accurate test, single factor correlation analysis and Kaplan-Meier survival analysis. Results: the clinicopathological characteristics of 1. pSS-MN cases were included in 42 cases of pSS-MN patients, accounting for 27.2% of pSS cases (154 cases) and pSS combined with glomerular disease (94 cases) with the clinical characteristics of 44.6%.: female mainly (76.2%) and the average age of 52.3 + 19 years; the incidence of the disease was mainly (50%) before the onset of the renal pSS (50%). Some patients had no obvious pSS symptoms (31%). The main clinical manifestations were nephrotic syndrome (85.7%), multiple microscopic hematuria (81%), 24 hours urine protein 4.6 + 3.1g/24h, serum albumin 26.5 7.3g/L, eGFR 92.8 + 26.3 ml/min.26.8% in patients with serum IgG increase, 20% patients with serum C3 or C4 complement level decreased.9 patients (21.4%) With chronic thyroiditis, the level of serum IgG in this group was significantly higher than that of other patients (28.6 + 6.9g/Lvs.19.8 + 7.3g/L, p0.001). The serum anti PLA2R antibody was detected in.15 patients, of which 8 cases (53.3%) and 7 cases (46.7%) were negative. 18 cases (42.9%) were atypical MN, with mesangial region hyperplasia, electronic dense deposit or Clq positive Characteristics: immunofluorescence C3 positive 43.9%, C1q positive 34.1%; of which 20 patients had IgG subtype immunofluorescence staining, IgG4 positive (95%), followed by IgG1 (55%), IgG3 (50%) and IgG2 (0%). The treatment was followed up: 97.6% patients received immunization, including full hormone combined cyclophosphamide (54.8%), mycophenolate mofetil. Or Tripterygium wilfordii (7.1%), half hormone combined with calcineurin inhibitor (19%), single use of full hormone (14.3%).25 patients were followed up for more than or equal to 6 months, the average follow-up time was 39 + 49.5 months, the median follow-up time was 24 months. 52% of the patients were completely or partially remission of nephrotic syndrome; 76% patients had stable renal function. 16% patients with creatinine slightly elevated or fluctuated, only 2 cases (8%) had renal function progression, with nephrotic syndrome not remission or recurrence, of which 1 cases had progressed to renal interstitial lymphocytic infiltration and ectopic germinal center in.2. pSS-MN cases of end-stage renal disease, 35 cases of pSS-MN patients completed CD21 staining and lymphocytic infiltration degree classification, GO (no) The proportion of G1 (a small amount), G2 (large) and G3 (ectopic germinal center like structure) was 5.7%, 34.3%, 28.6%, and 31.4%., respectively, of which 11 cases of G3 were seen in the renal interstitial dense focal lymphocytic infiltration, and the CD21 staining was positive for the typical dendritic cell network structure, and 7 of the germinal centers were adjacent to or wrapped around the glomeruli. Positive correlation between grade and sclerosing index (p=0.007), severe infiltration group (G2-G3) was lower than that of mild infiltration group (GO-G1) eGFR (85.7 + 26.7ml/min vs.100.6 + 23.2ml/min, p=0.068). The staining of T cells and subgroups in ectopic germinal center of two cases with larger clinical difference showed that the difference of germinal center components in different cases had a difference.3.. The expression of B7-1 and IL-17 pathway in pSS-MN cases has high expression of B7-1, which is significantly higher than that of mild lesions, which is mainly expressed in the renal interstitium and tubule epithelium, rarely in the glomeruli, but is common in the glomeruli, and there is no significant correlation between the expression of B7-1 and the clinical indicators of the 24 hour urine egg white and renal function at the time of biopsy. In the non remission group of nephrotic syndrome (p=0.044), the expression of local IL-17 in the kidney was elevated and the degree of B7-1 was positively correlated (p=0.048). The co expression of tubule and small ball IL-17RD in patients with pSS-MN was observed. Conclusion: in this study, it is observed that the most common renal glomerular lesions in 1.pSS are MN, and nearly half of the patients are pathological. It is an atypical membranous nephropathy with negative serum anti PLA2R antibody in nearly half of the patients, but there is no significant correlation between the two patients with.2. pSS-MN with different degrees of lymphocyte infiltration, near 1/3 with ectopic germinal center like structure, the severity of lymphocyte infiltration and renal function, glomerulosclerosis; 3.pSS-MN kidney The expression level of local B7-1 was significantly higher and had a good correlation with the prognosis of nephrotic syndrome. Local IL-17 in the kidney was positively correlated with the expression level of B7-1. IL-17 may be associated with IL-RD to mediate the expression of local B7-1 and the injury of ductal tube.

【學(xué)位授予單位】：北京協(xié)和醫(yī)學(xué)院
【學(xué)位級別】：博士
【學(xué)位授予年份】：2015
【分類號】：R593.2;R692
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本文編號：1815255