本文選題：常染色體顯性多囊腎病 + 尿液生物標(biāo)志物�。� 參考：《第二軍醫(yī)大學(xué)》2017年博士論文

【摘要】：研究目的:檢測常染色體顯性多囊腎病(ADPKD)患者的尿液蛋白譜,探究反映腎單位各節(jié)段損傷、腎臟局部炎癥和補(bǔ)體系統(tǒng)活性的尿蛋白指標(biāo)在ADPKD疾病進(jìn)程中的變化規(guī)律,同時(shí)聯(lián)合腎臟的功能指標(biāo)和結(jié)構(gòu)指標(biāo)以及PKD基因檢測結(jié)果,全面地評(píng)估ADPKD的疾病進(jìn)展,篩選具有臨床指導(dǎo)意義的尿液標(biāo)志物。研究方法:第一部分研究是一個(gè)由8家單位參與的、觀察性橫斷面研究,從2014年3月至2016年8月期間住院或門診隨訪的ADPKD患者中,按照CKD1-5期和男女比例1:1入組患者。采集病史,記錄實(shí)驗(yàn)室檢查結(jié)果,留取空腹清潔中段晨尿標(biāo)本和空腹血清標(biāo)本,應(yīng)用酶聯(lián)免疫吸附測定(ELISA)、散射比濁法、透射比濁法,同步檢測血、尿蛋白指標(biāo)的濃度。采用核磁共振成像技術(shù)(MRI)行雙側(cè)腎臟平掃并測算總腎體積(TKV)。根據(jù)CKD1組的多囊腎病患者一般特征,從健康體檢中心匹配正常人作為對照,男女比例1:1。研究的尿蛋白共計(jì)十種,所有尿蛋白均以尿肌酐值進(jìn)行標(biāo)化。腎小球損傷指標(biāo):尿白蛋白/肌酐比值(ACR)、尿轉(zhuǎn)鐵蛋白/肌酐(TRF/Cr)、尿免疫球蛋白G/肌酐(IgG/Cr),近端腎小管損傷指標(biāo):尿腎臟損傷分子/肌酐(KIM-1/Cr)、尿肝臟型脂肪酸結(jié)合蛋白/肌酐(L-FABP/Cr)、尿中性粒細(xì)胞明膠酶相關(guān)脂質(zhì)運(yùn)載蛋白/肌酐(NGAL/Cr)、尿視黃醇結(jié)合蛋白/肌酐(RBP/Cr)、尿α1-微球蛋白/肌酐(α1-MG/Cr),炎癥指標(biāo):尿單核細(xì)胞趨化蛋白-1(MCP-1/Cr),補(bǔ)體指標(biāo):尿補(bǔ)體B因子(CFB/Cr)。第二部分和第三部分是單中心、前瞻性、縱向隊(duì)列研究,選擇2014年3月至2016年12月我科定期隨訪的ADPKD患者,基線時(shí)患者的估算腎小球?yàn)V過率eGFR≥15ml/min*1.73m2,以eGFR≥30ml/min*1.73m2為主。每隔半年或1年來院隨訪1次,隨訪內(nèi)容包括病史采集、體格檢查、一般實(shí)驗(yàn)室檢查、基于MRI的TKV測量、尿液蛋白譜檢測(指標(biāo)及其檢測方法同第一部分)。第三部分的PKD基因檢測采用的是高通量測序方法。結(jié)果:第一部分“常染色體顯性多囊腎病患者尿蛋白譜與疾病進(jìn)展的多中心橫斷面研究”:研究共納入200名ADPKD患者,根據(jù)CKD1期患者,匹配了40名健康人作為正常對照。腎小球損傷指標(biāo)尿ACR、尿IgG/Cr和尿TRF/Cr在疾病早期(CKD1期)就顯著高于正常人(P0.01),尿ACR、尿IgG/Cr在ADPKD患者中,CKD1-2期內(nèi)整體的漲幅并不大,直到疾病后期(CKD3-5期)才會(huì)上升明顯(P0.05),尿TRF/Cr直到CKD4期才明顯上升(P0.001)。近端小管損傷指標(biāo)中,CKD1期患者同正常人相比,尿α1-MG/Cr和尿RBP/Cr無顯著差異,患者組間比較發(fā)現(xiàn)自CKD 3期開始,二者尿液濃度開始顯著上升(P0.05);患者尿NGAL/Cr高于正常人(p0.05),患者尿l-fabp/cr在疾病早期與正常人無顯著差異(p0.05),患者中至ckd4-5期,二者顯著上升,但是血清ngal濃度變化則比較早,在ckd2期時(shí)就已明顯上升(p0.05);ckd1期患者尿kim-1/cr顯著高于正常人,就adpkd患者而言,隨著ckd的進(jìn)展,尿kim-1/cr逐漸增加,至ckd4期達(dá)最高,ckd5期似有回落的趨勢(p0.05)。補(bǔ)體指標(biāo):ckd1患者的尿cfb/cr與正常人無異(p0.05),ckd1-3期內(nèi),尿cfb/cr差異不大,濃度均比較低,但是ckd4-5期患者尿cfb/cr濃度明顯上升(p0.001)。炎癥指標(biāo):ckd1患者的尿mcp-1/cr顯著高于正常人(p0.05),患者中隨著egfr下降,尿mcp-1/cr逐漸升高(p0.001),血清mcp-1濃度并不隨著疾病進(jìn)展而變化(p0.05)。所有尿蛋白指標(biāo)均與egfr呈負(fù)相關(guān)關(guān)系(p0.001)。對于早期患者(egfr≥60ml/min*1.73m2),尿mcp-1/cr與httkv的相關(guān)性優(yōu)于其它尿蛋白(r=0.396,p0.001)。對ckd1-3期的患者,進(jìn)一步作多元回歸分析發(fā)現(xiàn),尿acr、α1-mg/cr、mcp-1/cr與httkv是獨(dú)立相關(guān)的。第二部分“常染色體顯性多囊腎病患者尿蛋白譜與疾病進(jìn)展的前瞻隊(duì)列研究”:該隊(duì)列共納入了106名adpkd患者,中位隨訪時(shí)間2.0[1.7-2.2]年,大部分患者的腎功能儲(chǔ)備相對較好。隨訪過程中,adpkd患者的tkv的平均年變化值為79.4[23.8-148.4]cm3,tkv的平均年變化率(Δtkv%/year)為5.33%[2.48%-10.65%],egfr平均年變化值為-3.2±6.6ml/min*1.73m2,egfr平均年變化率為-4.2±8.7%。應(yīng)用roc曲線分析發(fā)現(xiàn):除了尿mcp-1和尿cfb之外的所有尿蛋白對基線egfr60ml/min*1.73m2均有診斷價(jià)值,以尿α1-mg/cr的診斷效能最佳,尿l-fabp/cr次之;基線尿mcp-1/cr對Δtkv%/year5%和Δtkv%/year≥6%均有預(yù)測作用。經(jīng)多因素logistic回歸分析,基線尿mcp-1/cr是Δtkv%/year5%和Δtkv%/year≥6%的獨(dú)立預(yù)測因子。第三部分“常染色體顯性多囊腎病患者尿蛋白譜與基因突變類型的關(guān)系”:該隊(duì)列共納入93名患者,主要來自第二部分的縱向隊(duì)列,中位隨訪時(shí)間是2.0[1.8-2.2]年,pkd基因檢測的陽性率是78.5%,20例患者未檢測出致病突變位點(diǎn),pkd2基因突變、pkd1基因非截短突變和pkd1基因截短突變的比例分別是12.9%、20.4%、45.2%。無adpkd家族史的患者檢測陰性率略高于有家族史患者(36.8%vs17.6%,p=0.13)。pkd突變類型并不影響tkv的增長速率(p0.05)。pkd1截短突變組患者的尿mcp-1/cr顯著高于pkd1基因非截短突變組(p0.05)。多元分析發(fā)現(xiàn):患者的年齡與egfr呈負(fù)相關(guān),男性性別、pkd1基因突變(尤其是pkd1截短突變)是egfr下降的獨(dú)立危險(xiǎn)因子,在眾多尿蛋白指標(biāo)中,尿acr、l-fabp/cr、kim-1/cr與egfr呈現(xiàn)獨(dú)立負(fù)相關(guān);以基線httkv為因變量,只有年齡和尿mcp-1/cr與HtTKV獨(dú)立相關(guān),二者和HtTKV呈現(xiàn)正相關(guān)關(guān)系。結(jié)論:尿MCP-1與腎臟功能指標(biāo)和結(jié)構(gòu)指標(biāo)(HtTKV)具有良好的相關(guān)性,也是腎臟體積快進(jìn)展的重要危險(xiǎn)因素和獨(dú)立預(yù)測因子。
[Abstract]:Objective: to detect the urine protein spectrum of the patients with autosomal dominant polycystic kidney disease (ADPKD), to explore the changes in the changes in the urinary protein indicators of the renal unit segments, local inflammation and complement system activity in the ADPKD disease process, and to combine the renal function and structural indexes as well as the PKD gene detection results. Evaluation of ADPKD's disease progression and screening of clinically guiding urine markers. Research methods: the first part of the study was an observational cross-sectional study involving 8 units of ADPKD patients who were hospitalized or outpatient follow-up from March 2014 to August 2016, and were enrolled in the group of patients according to the CKD1-5 period and the male and female ratio. Record the history of the disease. The results of the laboratory examination were recorded, and the morning urine specimens and empty serum specimens were left in the middle section of the empty abdomen. The enzyme linked immunosorbent assay (ELISA), turbidimetry and turbidimetry were used to detect the concentration of the blood and urine protein. The total renal volume (TKV) was measured by magnetic resonance imaging (MRI) and the total kidney volume (TKV) was measured by the CKD1 group. The general characteristics of nephrotic patients were compared with those of normal people in the health check-up center. The amount of urine protein in the male and female ratio 1:1. was ten. All the urine proteins were normalized by the value of urinary creatinine. Glomerular damage index: urinary albumin / creatinine ratio (ACR), urinary transferrin / creatinine (TRF/Cr), urinary immunoglobulin G/ creatinine (IgG/Cr), and small proximal kidney Vascular injury index: urinary kidney injury molecules / creatinine (KIM-1/Cr), urinary hepatic fatty acid binding protein / creatinine (L-FABP/Cr), urinary neutrophils related lipid carrier protein / creatinine (NGAL/Cr), urine retinol binding protein / creatinine (RBP/Cr), urinary alpha 1- microglobulin / creatinine (alpha 1-MG/Cr), inflammatory index: urinary monocyte chemoattractant protein -1 (MCP). -1/Cr), complement index: urinary complement B factor (CFB/Cr). The second and third parts are single center, prospective, longitudinal cohort study, and select ADPKD patients who are regularly followed up from March 2014 to December 2016. The estimated glomerular filtration rate of the patients at baseline is more than 15ml/min* 1.73m2, with eGFR more than 30ml/min*1.73m2, every half a year or 1 years. The hospital was followed up for 1 times, including medical history collection, physical examination, general laboratory examination, TKV measurement based on MRI, urine protein spectrum detection (index and detection method and the first part). The third part of PKD gene detection was using high flux sequencing method. Results: Part 1 "urinary protein spectrum of autosomal dominant polycystic kidney disease patients" A multicenter cross-sectional study with the progression of the disease: a total of 200 ADPKD patients were enrolled in the study. According to CKD1 patients, 40 healthy people were matched as normal controls. Glomerular damage index urine ACR, urine IgG/Cr and urine TRF/Cr were significantly higher than normal people (P0.01), urinary ACR, urinary IgG/Cr in ADPKD patients, and CKD1-2 period as a whole The increase was not significant until the later stage of the disease (CKD3-5 phase) increased significantly (P0.05), and the urine TRF/Cr was not significantly increased until CKD4 (P0.001). In the proximal tubule injury index, there was no significant difference in the urinary alpha 1-MG/Cr and urinary RBP/Cr in the CKD1 patients compared with the normal people. The urine concentrations began to rise significantly from the period of CKD 3, and the urine concentration began to rise significantly in the two patients ( P0.05): the urine NGAL/Cr of the patient was higher than that of the normal person (P0.05), and the urine l-fabp/cr was not significantly different from the normal person (P0.05) in the early stage of the disease (P0.05), and the two of the patients increased significantly in the middle to ckd4-5 stage, but the serum NGAL concentration was earlier and increased obviously at ckd2 phase (P0.05); the ckd1 phase patient's urine kim-1/cr was significantly higher than that of the normal person, as for ADPKD patients, With the progress of CKD, the urine kim-1/cr gradually increased and reached the highest ckd4 stage, and the ckd5 phase seemed to have a tendency to fall (P0.05). The complement index: the urine cfb/cr of the ckd1 patients was no different than that of the normal person (P0.05). During the period of ckd1-3, the urinary cfb/cr was not very different and the concentration was low, but the urinary cfb/cr concentration in the ckd4-5 phase was significantly higher. The urine mcp-1/cr was significantly higher than that of the normal person (P0.05), and the urine mcp-1/cr increased gradually with the decrease of EGFR (p0.001), and the serum MCP-1 concentration did not change with the progression of the disease (P0.05). All urinary protein indexes were negatively correlated with EGFR (p0.001). The correlation between the urinary mcp-1/cr and the urinary mcp-1/cr was better than that in the early patients (EGFR > 60ml/min*1.73m2). Other urinary proteins (r=0.396, p0.001). Further multivariate regression analysis for patients with ckd1-3 phase found that urinary ACR, alpha 1-mg/cr, mcp-1/cr and httkv are independent. Second a prospective cohort study of urinary protein and disease progression in patients with autosomal dominant polycystic kidney disease: the cohort was included in 106 ADPKD patients with a median follow-up During the period of 2.0[1.7-2.2], the renal function reserve of most patients was relatively good. During the follow-up process, the average annual variation of TKV in ADPKD patients was 79.4[23.8-148.4]cm3, the average annual change rate of TKV (delta tkv%/year) was 5.33%[2.48%-10.65%], and the average annual change of EGFR was -3.2 + 6.6ml/ min*1.73m2. The curve analysis showed that all urinary proteins except urinary MCP-1 and urinary CFB had diagnostic value for baseline egfr60ml/min*1.73m2, and the diagnostic efficiency of urinary alpha 1-mg/cr was the best and urine l-fabp/cr was l-fabp/cr. The baseline urine mcp-1/cr had a predictive effect on Delta tkv%/year5% and delta tkv%/year > 6%. The baseline urinary mcp-1/cr was a delta tkv%. The independent predictors of /year5% and delta tkv%/year > 6%. Part third the relationship between the urinary protein spectrum and gene mutation type in the patients with autosomal dominant polycystic kidney disease: the cohort included 93 patients, mainly from second parts of the longitudinal cohort, the median follow-up time was 2.0[1.8-2.2], and the positive rate of PKD gene detection was 78.5%, 20 patients. The proportion of PKD2 gene mutation, PKD1 gene untruncated and PKD1 gene truncated mutations was 12.9%, 20.4%, and 45.2%. without ADPKD family history was slightly higher than those with family history (36.8%vs17.6%, p=0.13).Pkd mutation type did not affect the TKV growth rate (P0.05).Pkd1 truncated mutation group. The urine mcp-1/cr of the patients was significantly higher than the non truncated PKD1 mutation group (P0.05). Multivariate analysis showed that the age of the patients was negatively correlated with the EGFR, and the male sex, the PKD1 gene mutation (especially the PKD1 truncated mutation) was an independent risk factor for EGFR decline, and the urinary ACR, l-fabp/cr, kim-1/cr and EGFR were negatively correlated in many urinary protein indicators; Line httkv is dependent on the dependent variable, only age and urine mcp-1/cr are independent of HtTKV, and there is a positive correlation between the two and HtTKV. Conclusion: urinary MCP-1 has a good correlation with renal function index and structural index (HtTKV). It is also an important risk factor and independent predictor of renal volume rapid progress.
【學(xué)位授予單位】：第二軍醫(yī)大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2017
【分類號(hào)】：R692

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