抗原呈递在原发性干燥综合征合并膜性肾病发病机制中意义的初步观察

发布时间：2018-04-28 12:22

  本文选题：原发性干燥综合征 + 膜性肾病　； 参考：《北京协和医学院》2015年博士论文

【摘要】：研究背景：原发性干燥综合征(primarySjogren Syndrome, pSS)是一种多器官受累的自身免疫病,其肾脏受累常见表现为间质性肾炎和肾小管酸中毒。关于pSS肾小球病变临床病理特征的报道较少。pSS肾脏受累的机制并不明确,既往认为与局部淋巴细胞浸润、T细胞亚群失调及自身抗体形成相关,近年来认识到异位生发中心形成和上皮细胞抗原呈递可能是pSS脏器炎症损伤的关键环节,传统认为只表达于专职抗原呈递细胞的共刺激分子B7-1(又称CD80),在病理状态下亦可表达于肾小管上皮细胞和肾小球足细胞,故可能是连接pSS管-球损伤的桥梁。小管损伤介导小球损伤的现象存在于Heymann'肾炎动物模型中,其所代表的膜性肾病(membranous nephropathy, MN)发病机制主要是由针对肾小球足细胞的特异性自身抗体在局部沉积,但在人体内尚不清楚该自身抗体是如何产生的。故本研究总结了北京协和医院近20年来原发性干燥综合征合并膜性肾病(pSS-MN)患者的临床病理特点,观察肾脏间质小管和肾小球异位生发中心形成及抗原呈递分子表达特点,试图探寻管-球共同损伤机制,寻找有可能影响其临床预后的相关特点,为进一步研究其发病机制和潜在的干预措施提供一些线索。研究目的：1.回顾性观察pSS-MN患者的临床病理特点、治疗及转归,初步分析影响其临床和预后的相关因素;2.评价pSS-N MN病例肾间质淋巴细胞浸润及异位生发中心形成情况,初步观察其淋巴细胞成分,分析其与临床指标及预后的关联性；3.观察pSS-MN病例肾脏局部抗原呈递分子B7-1及IL-17通路表达情况,观察二者与临床病理及预后的关联性。研究方法：回顾性纳入从1993年1月至2014年12月间在北京协和医院住院患者中选出经肾活检确诊,临床资料完整的pSS-MN病例,收集其临床、病理及随访资料,评价干燥综合征活动性；定义血肌酐升高大于50%、终末期肾病或死亡为主要终点事件,定义蛋白尿缓解为次要终点事件。对肾小球硬化、肾小管损伤及肾间质纤维化半定量分析。行CD21(生发中心树突细胞标记)免疫组化染色,评价间质淋巴细胞浸润分级和异位生发中心形成,行CD3(T细胞标记)、Foxp3(Treg细胞标记)及IL-17(Th17细胞标记)免疫组化或免疫荧光染色,初步观察生发中心细胞成分,并分析上述资料与临床病理及预后的关联性。行B7-1、IL-17A和IL-17RD(IL-17受体)免疫组化染色,观察其在间质浸润的炎症细胞、小管上皮细胞和足细胞的表达情况,并分析其表达水平与临床病理和预后的关联性。统计方法：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。统计软件为SPSS 19.0软件(IBM,USA)。主要统计方法包括t检验和秩和检验、ANOVA、Fisher精确检验、单因素相关分析和Kaplan-Meier生存分析等。研究结果：1. pSS-MN病例的临床病理特点共有42例pSS-MN患者纳入本研究,占同期行肾活检pSS病例(154例)的27.2%,pSS合并肾小球疾病病例(94例)的44.6%。临床特点：以女性为主(76.2%),平均年龄52.3±19.0岁；发病顺序以肾外pSS发病在前为主(50.0%),尚有部分患者无明显pSS症状(31.0%)。临床主要表现为肾病综合征(85.7%),多伴镜下血尿(81.0%),肾活检时24小时尿蛋白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补体水平减低。9例患者(21.4%)合并慢性甲状腺炎,该组患者血清IgG水平显著高于其他患者(28.6±6.9g/Lvs.19.8±7.3g/L,p0.001)。15例患者进行了血清抗PLA2R抗体检测,其中阳性8例(53.3%),阴性7例(46.7%)。病理特点：18例(42.9%)为不典型MN,以系膜区增生、电子致密物沉积或Clq阳性为特点；免疫荧光C3阳性者43.9%,C1q阳性者34.1%;其中20例患者进行了IgG亚型免疫荧光染色,以IgG4阳性为主(95%),其次为IgG1(55.0%)、IgG3(50.0%)和IgG2 (0%).治疗随访情况：97.6%的患者接受了免疫抑制治疗,包括足量激素联合环磷酰胺(54.8%)、霉酚酸酯或雷公藤多甙(7.1%),半量激素联合钙调蛋白磷酸酶抑制剂(19.0%),单用足量激素(14.3%)。25例患者随访时间大于或等于6个月,其平均随访时间39.0±49.5个月,中位随访时间24个月。其中52%患者肾病综合征完全或部分缓解；76.0%患者肾功能稳定,16%患者肌酐轻度升高或波动,仅2例(8%)患者出现肾功能进展,伴肾病综合征未缓解或复发,其中1例进展至终末期肾病。2. pSS-MN病例的肾间质淋巴细胞浸润及异位生发中心形成35例pSS-MN患者完成CD21染色并进行淋巴细胞浸润程度分级,GO(无)、G1(少量)、G2(大量)和G3(异位生发中心样结构形成)比例分别为5.7%、34.3%、28.6%和31.4%。其中11例G3级患者镜下可见肾间质密集灶性淋巴细胞浸润,CD21染色阳性呈典型树突细胞网结构,其中7例生发中心紧邻或包绕肾小球。间质淋巴细胞浸润分级与小球硬化指数正相关(p=0.007),严重浸润组(G2-G3)较轻微浸润组(GO-G1)eGFR水平临界偏低(85.7±26.7ml/min vs.100.6±23.2ml/min, p=0.068)。对临床差异较大的两例病例异位生发中心T细胞及亚群的染色观察提示,不同病例生发中心成分具有差异。3. pSS-MN病例的B7-1和IL-17通路表达情况pSS-MN患者存在B7-1高表达,显著高于轻微病变组,主要表达于肾间质和小管上皮,极少见于肾小球内,但围绕肾小球表达常见；B7-1表达水平与活检时24小时尿蛋白和肾功能等临床指标无显著相关性,但在肾病综合征未缓解组显著高于缓解组(p=0.044)。肾脏局部IL-17表达升高且程度与B7-1水平正相关(p=0.048)；可观察到pSS-MN患者小管和小球IL-17RD共表达。结论：在本研究条件下观察到：1.pSS合并肾小球病变以MN最多见,近半数患者病理上表现为不典型膜性肾病,同时近半数患者血清抗PLA2R抗体阴性,但二者之间无显著相关性。2. pSS-MN患者肾间质伴有不同程度的淋巴细胞浸润,近1/3伴异位生发中心样结构形成,淋巴细胞浸润严重程度与肾功能、肾小球硬化相关；3.pSS-MN肾脏局部B7-1表达水平显著升高,且与肾病综合征预后相关性好；肾脏局部IL-17与B7-1表达水平正相关,IL-17可能与IL-RD共同介导了局部B7-1的表达和球-管损伤。
[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.

【学位授予单位】：北京协和医学院
【学位级别】：博士
【学位授予年份】：2015
【分类号】：R593.2;R692
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本文编号：1815255