国产环孢菌素药代动力学特点及足细胞钙调磷酸酶表达与肾病综合征疗效分析

发布时间：2018-02-28 01:23

本文关键词： 肾病综合征环孢菌素血药浓度足细胞钙调磷酸酶　出处：《北京协和医学院》2014年硕士论文　论文类型：学位论文

【摘要】：研究背景肾病综合征是由多种病因引起的,以大量蛋白尿(3.58/d)、低白蛋白血症(30g/L)、高脂血症和水肿为特点的一组临床综合征。钙调磷酸酶抑制剂环孢菌素治疗肾病综合征已有不短的历史,但因为其潜在的毒副作用,常需监测血药浓度。研究证实肾移植病人,服药2小时后的血药浓度(C2)可较好反映环孢菌素暴露程度,但如何选择肾病综合征患者血药浓度监测点的研究较少,鲜有国产环孢菌素治疗肾病综合征药代动力学前瞻性研究,血药浓度与疗效及肾毒性关系也存有争论。近年来观察到部分原发肾病综合征(膜性肾病和局灶性节段性肾小球硬化)足细胞钙调磷酸酶表达上调,可能通过增加肾小球滤过屏障的通透性,导致蛋白尿。但是足细胞钙调磷酸酶表达差异是否与蛋白尿的量相关,与钙调磷酸酶抑制剂疗效的关系尚不清楚。研究目的 1、前瞻性观察国产环孢菌素治疗肾病综合征患者药代动力学特点,确定最佳血药浓度监测点,进而分析血药浓度与临床疗效及肾毒性的关系； 2、观察原发性膜性肾病和局灶性节段性肾小球硬化患者足细胞钙调磷酸酶表达差异与蛋白尿及临床疗效的关系。研究方法第一部分为前瞻性研究,自2009年10月至2012年2月在北京协和医院接受国产环孢菌素田可治疗的肾病综合征患者28例,收集其临床、病理及资料,前瞻性监测服药前,空腹服药后1、2、3和4小时血药浓度(全血高效液相法)。分析不同监测点环孢菌素血药浓度与0-4小时药时曲线下面积(the area under the concentration-time curve up to4h post-dose, AUCO-4)的相关性,确定最佳监测点。随诊6月,监测第1、2、3、6个月服药前、空腹服药后1小时和2小时的血药浓度,观察血药浓度与疗效及肾损害的相关性。第二部分为回顾性病例对照研究,自2009年10月至2013年12月北京协和医院肾内科住院病人中选出临床病理资料完整、且有足够肾活检标本的MN(20例)及FSGS(10例)；收集其临床、病理及随访资料。常规行病理分析,行钙调磷酸酶和WT1(足细胞特异性标记)免疫组化染色,Synaptopodin (足细胞骨架蛋白分子)免疫荧光染色,分析足细胞钙调磷酸酶表达与足细胞损害程度及疗效的相关性。连续变量以均值±标准差的形式表示,计数资料以构成比表示,采用SPSS19.0软件(IBM, USA)。正态分布计量数据比较采用t检验,计数数据两组比较采用卡方检验。计量、计数资料相关分析分别采用Pearson相关和Spearman相关分析。研究结果 1、肾病综合征患者环孢菌素(田可)AUC0-4与各时间点血药浓度的相关性选择时间点越多,与AUC0-4的相关性越好,选3个时间点监测血药浓度时,C1C2C3与AUC0-4相关性最好(r=0.992,P0.05)；选2个时间点监测血药浓度,C1C3与AUC0-4相关性最好(r=0.952,P0.05),ClC2与AUC0-4相关性次之(r=0.913,P0.05)；选1个时间点测量血药浓度,C2与AUC0-4相关性最好(r=0.832,P0.05)。目前临床上常用测定环孢菌素C0、C2,C0C2与AUC0-4的相关性(r=0.842,P0.05)略优于C2单点监测(r=0.832,P0.05)。 2、肾病综合征患者环孢菌素血药浓度与临床疗效无关,与肾毒性相关随访3个月,完全缓解(8例)、部分缓解(13例)及未缓解(7例)病人的C0(123.77±58.52ng/ml比87.55±37.59ng/ml比152.47±91.3ng/ml)、C1(553.7±414.4ng/ml比420.44±228.05ng/ml比603.9±478.35ng/ml)和C2(680.8±69.56ng/ml比530.92±352.9ng/ml比575.75±377.9ng/ml)之间均无明显统计学差异。但是发生肾损害(血肌酐升高超过30%)患者C0、C1血药浓度明显高于无肾损害患者(183.86±82.76ng/ml比103.09±38.73ng/ml,P0.05；892.97±367.48ng/ml比479.35±287.9ng/ml,P0.05),而两组病人的C2(556.85±278.24ng/ml比536.58±247.1ng/ml)水平无统计学差异。 3、原发性MN和原发性FSGS患者足细胞钙调磷酸酶表达与疗效相关随访6个月,3例足细胞钙调磷酸酶无表达患者均对环孢菌素治疗无反应。治疗3月有效病人(n=22)足细胞钙调磷酸酶表达水平明显高于8例无效病人(11.26±4.18%比6.92±4.09%,P0.05)；治疗6个月,24例有效病人足细胞钙调磷酸酶表达水平明显高于6例无效病人(10.96±3.69%vs3.93±2.38%,P0.05)。本研究中没有观察到足细胞钙调磷酸酶表达与蛋白尿的关系,但观察到存在钙调磷酸酶表达的肾小球伴有synaptopodin线性缺失,其中FSGS患者足细胞损伤重,WTl表达明显低于轻微病变组。研究结论本研究条件下 1、国产环孢菌素(田可)治疗肾病综合征患者,监测服药后不同时间点血药浓度中,C1C2C3,C1C3和C2分别为最佳多点和单一血药浓度时间测量点,可以较准确反映药物暴露程度； 2、在一定血药浓度范围内,临床疗效与环孢菌素血药浓度无关,但C0、C1点血药浓度与肾毒性相关； 3、环孢菌素治疗有效原发性MN和FSGS患者足细胞钙调磷酸酶表达明显高于治疗无效患者,没有观察到钙调磷酸酶表达与蛋白尿程度的关系。
[Abstract]:Research background
Nephrotic syndrome is caused by a variety of causes, with massive proteinuria (3.58/d), serum albumin (30g/L), hyperlipidemia and edema characterized by a clinical syndrome. The treatment of nephrotic syndrome has not short phosphatase inhibitor cyclosporin a calcium history, but because of its potential toxicity the role, often need to monitoring the blood concentration. The study confirmed that the renal transplant patients, serum concentration of medication after 2 hours (C2) can reflect the cyclosporine exposure, but how to choose the nephrotic syndrome in patients with blood concentration monitoring points less, few domestic cyclosporine treatment nephrotic syndrome prospectively the power generation also has preschool medicine syndrome, blood drug concentration and efficacy and renal toxicity. In recent years, the debate over observed part of primary nephrotic syndrome (membranous nephropathy and focal segmental glomerulosclerosis) podocyte calcineurin expression may be associated with the kidney The permeability of glomerular filtration barrier leads to proteinuria. However, whether the difference in expression of calcineurin in podocytes is related to the amount of proteinuria and the relationship between calcineurin inhibitors and the efficacy of calcineurin inhibitors is not clear.
research objective
1, we prospectively observed the pharmacokinetic characteristics of domestic cyclosporin in the treatment of nephrotic syndrome, determined the best blood concentration monitoring points, and further analyzed the relationship between plasma concentration and clinical efficacy and nephrotoxicity.
2, to observe the relationship between the difference in the expression of calcineurin in the podocytes of patients with primary membranous nephropathy and focal segmental glomerulosclerosis, and the relationship between proteinuria and clinical efficacy.
research method
The first part is a prospective study from October 2009 to February 2012 to accept domestic cyclosporin A in Peking Union Medical College Hospital in Tian can treat the patients with nephrotic syndrome in 28 cases, the clinical and pathological data, and prospective monitoring before taking medication after 4 hours of fasting and 1,2,3 blood drug concentration (whole blood high performance liquid chromatography) analysis. Different monitoring points of cyclosporine blood concentration and 0-4 hours in the area under the concentration time curve (the area under the concentration-time curve up to4h post-dose, AUCO-4) correlation, determine the optimum monitoring point. The follow-up monitoring in June, the first 1,2,3,6 months before medication, fasting medication after 1 hours and 2 hours of blood concentration. To study the correlation between serum drug concentration and efficacy of renal damage. The second part is a retrospective case-control study, patients were selected from the clinical and pathological data were complete in October 2009 to December 2013 in Peking Union Medical College Hospital Department of Nephrology, and Adequate renal biopsy specimens of MN (n = 20) and FSGS (10 cases); the clinical, pathological and follow-up data. Routine pathological analysis, for calcineurin and WT1 (podocyte specific marker) immunohistochemical staining, Synaptopodin (podocyte cytoskeleton protein) by immunofluorescence staining, the correlation analysis of foot cell calcineurin expression and podocyte damage and the effect of continuous variables. Expressed as mean standard deviation form, count data to the constituent ratio, using SPSS19.0 software (IBM, USA). Normal distribution of measurement data were compared using t test, count data of two groups were compared by chi square test. The measurement of Pearson. Correlation and Spearman correlation analysis were used to analysis of count data.
Research results
1, the correlation between cyclosporin (Tian Ke) AUC0-4 and blood concentration at various time points in patients with nephrotic syndrome
Select the time more and better correlation between AUC0-4, 3 time monitoring of blood drug concentration, the best correlation between C1C2C3 and AUC0-4 (r=0.992, P0.05); the 2 time points of monitoring the blood concentration, the best correlation between C1C3 and AUC0-4 (r=0.952, P0.05), ClC2 and AUC0-4 correlation times (r=0.913, P0.05); selected 1 time points to measure the blood concentration, the best correlation between C2 and AUC0-4 (r=0.832, P0.05). The common clinical determination of cyclosporin C0, C2, C0C2 and AUC0-4 correlation (r=0.842, P0.05) C2 is better than that of single point monitoring (r=0.832, P0.05).
2, cyclosporin blood concentration in patients with nephrotic syndrome is not related to clinical efficacy and is associated with renal toxicity.
After 3 months of follow-up, complete remission (8 cases), partial remission (13 cases) and non remission (7 cases) of patients with C0 (123.77 + 58.52ng/ml 87.55 + 37.59ng/ml 152.47 + 91.3ng/ml), C1 (553.7 + 414.4ng/ml 420.44 + 228.05ng/ml 603.9 + 478.35ng/ml) and C2 (680.8 + 69.56ng/ ml 530.92 + 352.9ng/ml 575.75 + 377.9ng/ml) were no significant difference. But the incidence of kidney damage (serum creatinine increased more than 30%) of patients with C0, patients with the blood concentration of C1 was significantly higher than those without renal damage (183.86 + 82.76ng/ml 103.09 + 38.73ng/ml, 892.97 + P0.05; 367.48ng/ml 479.35 + 287.9ng/ml, P0.05), and the two group patients with C2 (556.85 + 278.24ng/ml 536.58 + 247.1ng/ml) no significant difference.
3, the expression of calcineurin in the podocyte of primary MN and primary FSGS patients is associated with the effect
After 6 months of follow-up, 3 cases of podocyte calcineurin expression patients on cyclosporine treatment without reaction. Effective treatment in March patients (n=22) podocyte calcineurin expression level was significantly higher than that of 8 cases of invalid patients (11.26 + 4.18% to 6.92 + 4.09%, P0.05); 6 months of treatment, 24 cases effective patient podocyte calcineurin expression level was significantly higher than that of 6 cases of invalid patients (10.96 + 3.69%vs3.93 + 2.38%, P0.05). This study did not observe podocyte calcineurin expression and proteinuria, but observed glomerular synaptopodin associated with linear missing expression of calcineurin, which FSGS patients with podocyte injury again, the expression of WTl was significantly lower than that in mild lesion group.
research conclusion
Under the conditions of this study
1, the domestic cyclosporin (Tian Ke) treatment of nephrotic syndrome patients, after monitoring the serum concentration of C1C2C3 at different time points, C1C3, C2 were the best multi-point and single blood concentration time measurement points, which can accurately reflect the degree of drug exposure.
2, in a certain blood concentration range, the clinical efficacy was not related to the concentration of cyclosporin, but the concentration of C0 and C1 was associated with renal toxicity.
3, the expression of calcineurin in podocyte in patients with primary MN and FSGS was significantly higher than that in ineffective treatment with cyclosporine.

【学位授予单位】：北京协和医学院
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R692

【参考文献】