江苏地区抗结核药致肝损伤的发生及其与NRF2-ARE信号通路的遗传易感性研究

发布时间：2018-03-05 04:00

本文选题：抗结核药致肝损伤　切入点：发生率　出处：《南京医科大学》2017年硕士论文　论文类型：学位论文

【摘要】：结核病(Tuberculosis,TB)是由结核分支杆菌引起的慢性呼吸道传染病,通常感染并破坏肺部及淋巴系统,也可感染脑膜、腹膜、肠、皮肤、肾脏及骨骼等部位,为全球重大的公共卫生问题。随着标准短期化疗方案的全面覆盖,我国结核病防治取得一定的成效。但由于长时间、多种药物的联合使用,结核病人会出现各种不同程度的不良反应,其中以抗结核药致肝损伤(anti-tuberculosis liver injury,ATLI)较为常见且最为严重。目前学者们对影响ATLI发生的因素进行广泛探讨,非遗传因素涉及性别、年龄、疾病涉及的器官及其严重程度、营养状况、饮酒情况、肝炎病毒携带情况、保肝药使用情况等。遗传因素研究主要集中在N-乙酰基转移酶2、CYP450家族、GSTs转移酶超家族等相关药物代谢酶的基因突变,但是结果并不一致。除此之外,研究者们认为结核药在代谢过程中产生的过多毒性中间产物与肝细胞内的脂类、蛋白、核酸等大分子物质共价结合,促进活性氧(reactive oxygen,ROS)的产生,是ATLI发生的主要原因。机体在应对ROS损伤时,形成一整套复杂且有效的氧化应激反馈系统。当机体产生过高水平ROS时,自身能诱导出一系列保护性蛋白,从而缓解细胞所受的损害。在此过程中,核因子E2相关因子2-抗氧化反应元件(NRF2-ARE)信号通路诱导解毒酶和抗氧化物酶的表达,是重要的抗氧化应激信号通路。由此推测通路上相关蛋白(NRF2/KEAP1/MAFF/MAFK)的基因多态性会影响ROS的清除,进而导致ATLI的发生。本研究从非遗传因素和遗传因素为出发点,分别探讨可能影响ATLI发生的有关因素。第一部分抗结核药致肝损伤的发生及影响因素分析基于2014-2016年江苏地区4个医院(镇江市第三人民医院、句容市人民医院、泰兴市人民医院以及常熟市第二人民医院传染病分院)的结核病人随访队列,收集患者的流行病学资料及肝功能记录;同时,进一步基于镇江市第三人民医院2006-2012年结核病人病案资料及出院后门诊随访记录,依据病案及肝功能检测记录,采用国际共识会议标准诊断抗结核药致肝损伤(ATLI),对其相关因素进行分析。主要结果如下:1.在2014-2016年随访队列中,共纳入2209名结核患者,其中313名患者发生ATLI,发生率为14.2%(95%CI:12.7%-15.7%),中位发生时间为24天(四分位数间距为8.5～45天)。2006-2012年住院抗结核治疗病人共1967名,其中325名患者发生ATLI,发生率为16.5%(95%CI:14.9%-18.1%),中位发生时间为25天(四分位数间距为12-46.5天)。2.采用Cox回归模型进行多因素分析,结果显示男性ATLI发生率高于女性(HR=1.580,95%:1.076-2.315,P=0.019),使用包含 HRZ 治疗方案组ATLI 发生率高于其他方案组(HR=1.654,95%:1.147-2.386,P=0.007),耐药结核病人ATLI发生率高于非耐药结核病人(HR=2.935,95%:1.121-7.681,P=0.028),其差异均有统计学意义。第二部分NRF2-ARE信号通路相关基因遗传变异与抗结核药致肝损伤易感性的关系利用江苏地区四个医院2014-2016年新登记报告的结核病人建成的队列,采用1:2匹配的巢式病例对照研究设计,以候选基因组策略选取NRF2-ARE信号通路上的NRF2、KEAP1、MAFF、MAFK四个基因的15个标签SNPs,应用Sequenom Mass Array基因分型方法检测全部研究对象(313例ATLI病例,626例无ATLI对照)各SNP位点的基因型,运用条件Logistic回归分析四个基因位点多态性与ATLI发生的关联性。主要结果如下:条件Logistic回归分析显示,在调整保肝药物和治疗方案使用情况后,15个多态性位点基因型分布与ATLI的发生无统计学关联(P0.05)。分层分析显示,在女性患者中,KEAP1-rs11545829 TT基因突变型较CT+CC基因型发生ATLI 的危险性增加(隐性模型,OR=5.825,95%CI:1.800-18.850,P=0.003)。单倍型频率分布比较显示,四个基因中的各个单倍型频率分布在病例组与对照组间的差异均无统计学意义,未发现与ATLI有统计学关联的单倍型(P0.05)。交互作用分析发现,携带KEAP1-rs1048290位点GC+CC基因型且使用保肝药者较GG基因型而未使用保肝药者增加ATLI发病风险(OR=2.410,95%CI:1.104-5.261,P=0.027),但经 Bonferroni 校正后P0.05。联合作用分析发现,随着个体携带危险等位基因数量的增加,ATLI的患病风险逐步增加(P趋势=0.023)。
[Abstract]:Tuberculosis (Tuberculosis, TB) is a chronic respiratory infectious disease caused by Mycobacterium tuberculosis, usually infection and damage to the lungs and lymph system, also can infect the meninges, peritoneum, intestinal, kidney and skin, bones and other parts, as the major public health problem in the world. With the comprehensive coverage of the standard short-term chemotherapy, tuberculosis prevention and control our country has made some achievements. But for a long time, the combined use of multiple drugs, TB patients will appear different degree of adverse reactions, including anti tuberculosis drug induced liver injury (anti-tuberculosis liver, injury, ATLI) is a common and most serious factors were widely discussed. At present scholars on the incidence of ATLI. Non genetic factors related to gender, age, disease severity and involved organs, nutritional status, alcohol consumption, carrying hepatitis B virus, drug use and so on. The study of genetic factors To concentrate on the N- acetyltransferase 2, CYP450 family, GSTs transferase superfamily and related drug metabolizing enzyme gene mutation, but the results are not consistent. In addition, the researchers think that the fat, tuberculosis drugs produced in the metabolic process of excessive toxicity of intermediate and liver cells protein covalent nucleic acid binding, promote ROS (reactive oxygen ROS) which is the main reason for the occurrence of ATLI. The body in response to ROS damage and oxidative stress in the formation of a set of complex and effective feedback system. When the body produces high levels of ROS, itself can induce a series of protective proteins, thereby relieve cell injury. In this process, the nuclear factor E2 related factor 2- antioxidant response element (NRF2-ARE) induced expression of detoxifying enzymes and antioxidant enzyme pathway, oxidative stress is an important signaling pathway inferred through. The road related protein (NRF2/KEAP1/MAFF/MAFK) gene polymorphism may affect the ROS removal, and then lead to the occurrence of ATLI. This study from non genetic factors and genetic factors as a starting point, respectively, to explore related factors may influence the occurrence of ATLI. The incidence and related factors of liver injury induced by antituberculosis drugs in the first part of 2014-2016 years in Jiangsu based on the 4 hospital (Zhenjiang Third People's Hospital, Jurong People's Hospital, Taixing City People's Hospital, Changshou City Second People's Hospital of Infectious Diseases Branch) the tuberculosis patient follow-up cohort, epidemiological data were collected and recorded the liver function; at the same time, based on further follow-up records of Zhenjiang Third People's Hospital medical records of tuberculosis patients and 2006-2012 years after discharge, according to medical records and liver function test record the international consensus criteria for the diagnosis of anti tuberculosis drug induced liver injury (ATLI), on the phase The relevant factors were analyzed. The main results are as follows: 1. in the 2014-2016 year follow-up cohort, 2209 tuberculosis patients were included, of which 313 patients had ATLI, the incidence rate was 14.2% (95%CI:12.7%-15.7%), the median time was 24 days (the four percentile interval is 8.5 ~ 45 days) of.2006-2012 hospital anti tuberculosis treatment patients a total of 1967, of which 325 patients had ATLI, the incidence rate was 16.5% (95%CI:14.9%-18.1%), the median time was 25 days (four percentile interval of 12-46.5 days).2. Cox regression model was used for multivariate analysis, results showed that the male incidence rate of ATLI is higher than that of the female (HR=1.580,95%: 1.076-2.315, P=0.019), including HRZ treatment group ATLI was higher than other groups (HR=1.654,95%: 1.147-2.386, P=0.007), drug-resistant TB incidence rate of ATLI was higher than that of non drug resistant tuberculosis (HR=2.935,95%: 1.121-7.681, P=0.028), the differences were statistically Meaning. Tuberculosis related to liver injury induced by susceptibility genes related to genetic variation in the second part of the NRF2-ARE signaling pathway and the use of anti tuberculosis drugs in four hospitals in Jiangsu 2014-2016 years of new registration report completion queue, a nested case control study, 1:2 design, the candidate genomic selection strategies in NRF2-ARE signal pathway of NRF2, KEAP1. MAFF, 15 tag SNPs MAFK four gene, using Sequenom Mass Array genotyping method for the detection of all subjects (313 ATLI cases, 626 cases of non ATLI control) genotypes of each locus SNP, using conditional Logistic regression analysis of four SNPs and ATLI. The main results are as follows conditional Logistic regression analysis showed that in the adjustment of hepatoprotective drugs and treatment programs use, 15 genotype distribution of polymorphic loci and ATLI no significant correlation (P0.05). Stratified analysis showed that in female patients, KEAP1-rs11545829 TT gene mutation risk type with CT+CC genotype of ATLI increased (recessive model, OR=5.825,95%CI:1.800-18.850, P=0.003). The comparison shows that the frequency distribution of haplotypes, four genes in each haplotype frequency distribution in the case group and the control group had no significant difference, there is no statistics associated with ATLI haplotypes was found (P0.05). The interaction analysis found that carrying the KEAP1-rs1048290 GC+CC genotype and liver protection drugs than GG genotype without the use of liver protection drugs increase the risk of ATLI (OR=2.410,95%CI:1.104-5.261, P=0.027), but the combined effect of P0.05. after Bonferroni correction analysis showed that with the increase of the individual carrying dangerous number of alleles, the risk of ATLI increased gradually (P =0.023).

【学位授予单位】：南京医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R52

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