常染色体显性多囊肾病患者尿蛋白谱与疾病进展的相关性研究

发布时间：2018-06-17 04:23

本文选题：常染色体显性多囊肾病 + 尿液生物标志物　；参考：《第二军医大学》2017年博士论文

【摘要】：研究目的:检测常染色体显性多囊肾病(ADPKD)患者的尿液蛋白谱,探究反映肾单位各节段损伤、肾脏局部炎症和补体系统活性的尿蛋白指标在ADPKD疾病进程中的变化规律,同时联合肾脏的功能指标和结构指标以及PKD基因检测结果,全面地评估ADPKD的疾病进展,筛选具有临床指导意义的尿液标志物。研究方法:第一部分研究是一个由8家单位参与的、观察性横断面研究,从2014年3月至2016年8月期间住院或门诊随访的ADPKD患者中,按照CKD1-5期和男女比例1:1入组患者。采集病史,记录实验室检查结果,留取空腹清洁中段晨尿标本和空腹血清标本,应用酶联免疫吸附测定(ELISA)、散射比浊法、透射比浊法,同步检测血、尿蛋白指标的浓度。采用核磁共振成像技术(MRI)行双侧肾脏平扫并测算总肾体积(TKV)。根据CKD1组的多囊肾病患者一般特征,从健康体检中心匹配正常人作为对照,男女比例1:1。研究的尿蛋白共计十种,所有尿蛋白均以尿肌酐值进行标化。肾小球损伤指标:尿白蛋白/肌酐比值(ACR)、尿转铁蛋白/肌酐(TRF/Cr)、尿免疫球蛋白G/肌酐(IgG/Cr),近端肾小管损伤指标:尿肾脏损伤分子/肌酐(KIM-1/Cr)、尿肝脏型脂肪酸结合蛋白/肌酐(L-FABP/Cr)、尿中性粒细胞明胶酶相关脂质运载蛋白/肌酐(NGAL/Cr)、尿视黄醇结合蛋白/肌酐(RBP/Cr)、尿α1-微球蛋白/肌酐(α1-MG/Cr),炎症指标:尿单核细胞趋化蛋白-1(MCP-1/Cr),补体指标:尿补体B因子(CFB/Cr)。第二部分和第三部分是单中心、前瞻性、纵向队列研究,选择2014年3月至2016年12月我科定期随访的ADPKD患者,基线时患者的估算肾小球滤过率eGFR≥15ml/min*1.73m2,以eGFR≥30ml/min*1.73m2为主。每隔半年或1年来院随访1次,随访内容包括病史采集、体格检查、一般实验室检查、基于MRI的TKV测量、尿液蛋白谱检测(指标及其检测方法同第一部分)。第三部分的PKD基因检测采用的是高通量测序方法。结果:第一部分“常染色体显性多囊肾病患者尿蛋白谱与疾病进展的多中心横断面研究”:研究共纳入200名ADPKD患者,根据CKD1期患者,匹配了40名健康人作为正常对照。肾小球损伤指标尿ACR、尿IgG/Cr和尿TRF/Cr在疾病早期(CKD1期)就显著高于正常人(P0.01),尿ACR、尿IgG/Cr在ADPKD患者中,CKD1-2期内整体的涨幅并不大,直到疾病后期(CKD3-5期)才会上升明显(P0.05),尿TRF/Cr直到CKD4期才明显上升(P0.001)。近端小管损伤指标中,CKD1期患者同正常人相比,尿α1-MG/Cr和尿RBP/Cr无显著差异,患者组间比较发现自CKD 3期开始,二者尿液浓度开始显著上升(P0.05);患者尿NGAL/Cr高于正常人(p0.05),患者尿l-fabp/cr在疾病早期与正常人无显著差异(p0.05),患者中至ckd4-5期,二者显著上升,但是血清ngal浓度变化则比较早,在ckd2期时就已明显上升(p0.05);ckd1期患者尿kim-1/cr显著高于正常人,就adpkd患者而言,随着ckd的进展,尿kim-1/cr逐渐增加,至ckd4期达最高,ckd5期似有回落的趋势(p0.05)。补体指标:ckd1患者的尿cfb/cr与正常人无异(p0.05),ckd1-3期内,尿cfb/cr差异不大,浓度均比较低,但是ckd4-5期患者尿cfb/cr浓度明显上升(p0.001)。炎症指标:ckd1患者的尿mcp-1/cr显著高于正常人(p0.05),患者中随着egfr下降,尿mcp-1/cr逐渐升高(p0.001),血清mcp-1浓度并不随着疾病进展而变化(p0.05)。所有尿蛋白指标均与egfr呈负相关关系(p0.001)。对于早期患者(egfr≥60ml/min*1.73m2),尿mcp-1/cr与httkv的相关性优于其它尿蛋白(r=0.396,p0.001)。对ckd1-3期的患者,进一步作多元回归分析发现,尿acr、α1-mg/cr、mcp-1/cr与httkv是独立相关的。第二部分“常染色体显性多囊肾病患者尿蛋白谱与疾病进展的前瞻队列研究”:该队列共纳入了106名adpkd患者,中位随访时间2.0[1.7-2.2]年,大部分患者的肾功能储备相对较好。随访过程中,adpkd患者的tkv的平均年变化值为79.4[23.8-148.4]cm3,tkv的平均年变化率(Δtkv%/year)为5.33%[2.48%-10.65%],egfr平均年变化值为-3.2±6.6ml/min*1.73m2,egfr平均年变化率为-4.2±8.7%。应用roc曲线分析发现:除了尿mcp-1和尿cfb之外的所有尿蛋白对基线egfr60ml/min*1.73m2均有诊断价值,以尿α1-mg/cr的诊断效能最佳,尿l-fabp/cr次之;基线尿mcp-1/cr对Δtkv%/year5%和Δtkv%/year≥6%均有预测作用。经多因素logistic回归分析,基线尿mcp-1/cr是Δtkv%/year5%和Δtkv%/year≥6%的独立预测因子。第三部分“常染色体显性多囊肾病患者尿蛋白谱与基因突变类型的关系”:该队列共纳入93名患者,主要来自第二部分的纵向队列,中位随访时间是2.0[1.8-2.2]年,pkd基因检测的阳性率是78.5%,20例患者未检测出致病突变位点,pkd2基因突变、pkd1基因非截短突变和pkd1基因截短突变的比例分别是12.9%、20.4%、45.2%。无adpkd家族史的患者检测阴性率略高于有家族史患者(36.8%vs17.6%,p=0.13)。pkd突变类型并不影响tkv的增长速率(p0.05)。pkd1截短突变组患者的尿mcp-1/cr显著高于pkd1基因非截短突变组(p0.05)。多元分析发现:患者的年龄与egfr呈负相关,男性性别、pkd1基因突变(尤其是pkd1截短突变)是egfr下降的独立危险因子,在众多尿蛋白指标中,尿acr、l-fabp/cr、kim-1/cr与egfr呈现独立负相关;以基线httkv为因变量,只有年龄和尿mcp-1/cr与HtTKV独立相关,二者和HtTKV呈现正相关关系。结论:尿MCP-1与肾脏功能指标和结构指标(HtTKV)具有良好的相关性,也是肾脏体积快进展的重要危险因素和独立预测因子。
[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.
【学位授予单位】：第二军医大学
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R692

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