淫羊藿胶囊调节骨矿化治疗绝经后骨质疏松症的疗效观察和机制研究

发布时间：2018-04-23 16:14

本文选题：骨矿化异常 + 胎球蛋白A-基质gla蛋白-钙磷矿化复合物　；参考：《湖北中医药大学》2016年博士论文

【摘要】：目的从理论研究的角度总结绝经后骨质疏松症(PMOP)的发病机制,从临床研究的角度探索PMOP患者基质gla蛋白(MGP)与骨代谢的关系及胎球蛋白A-基质gla蛋白-钙磷矿化复合物(FMC)参与PMOP的发病机制,并观察中药淫羊藿胶囊治疗PMOP患者(肾阳亏虚证)的临床疗效和作用机制。方法1、理论研究:查阅文献,总结PMOP的发病机制,分析骨矿化异常与PMOP之间的关系;对古今相关文献进行系统的回顾总结,以了解中医对PMOP的病因病机及治则治法的认识,为临床试验研究提供理论依据。2、血清基质gla蛋白与骨代谢的相关性:本研究录入120例PMOP患者和60例骨量正常的绝经后妇女。通过聚合酶链式反应(PCR)检测血清MGP m RNA水平,骨状态通过骨密度(BMD)和骨转换标志物(β-CTX,P1NP)评估。此外,也检测血清雌二醇(E2)、甲状旁腺素(PTH)、血钙(Ca)、血磷(P)水平。3、胎球蛋白A-基质gla蛋白-钙磷复合体(FMC)参与PMOP的机制研究:选取行腰椎手术的PMOP患者和骨量正常的绝经后女性各23例,在手术时取其部分腰椎骨组织,患者血清胎球蛋白A(fetuin A)、基质gla蛋白(MGP)、骨形态发生蛋白2(BMP2)、runt相关转录因子2(RUNX2)水平采用酶联免疫吸附法(ELISA)检测,骨组织局部fetuin A、MGP、BMP2、RUNX2 m RNA及蛋白的表达则分别通过PCR及免疫组化的方法检测。4、中药疗效研究:选取PMOP患者90例,将其随机双盲分为A组(安慰剂对照组)、B组(淫羊藿胶囊低剂量组)及C组(淫羊藿胶囊高剂量组),共治疗24周。于治疗前和治疗24周后,观测患者疼痛VAS评分、主要症候评分、中医证候积分疗效变化,并检测患者BMD、血清中PINP、β-CTX及血清Fetuin-A、MGP水平的变化。统计学的处理:数据的分析处理采用统计软件SPSS 20.0进行,所有的数据都用均数±标准差(x±s)的形式表示,统计结果出现P0.05则认为差异具有统计学的意义。结果1、查阅文献,研究表明骨矿化异常是OP/PMOP的发病原因之一,FMC的形成是维持正常骨矿化的重要机制,但FMC是如何参与OP/PMOP发病的尚不清楚;中医学认为OP/PMOP的发病关键在于多种原因导致的肾虚髓亏,还与脾胃虚弱、肝血不足、瘀血阻滞有关。此外,我的导师向楠教授痰浊也是OP发病的重要因素。因此中医药治疗OP/PMOP也以补肾为基础,补肾中药是否能够通过影响骨矿化从而改善OP/PMOP的临床症状有待研究。2、PMOP组与非骨质疏松组相比,BMD、MGP m RNA、β-CTX、P1NP的差异有统计学意义(P0.05)。PMOP患者血清MGP m RNA水平显著低于对照组(0.835±0.415 VS 4.524±0.769,P0.001),与BMD(r=0.376,P0.001)、E2(r=0.227,P=0.013)呈正相关。未发现MGPm RNA与年龄、身高、体重、PTH、Ca、P、β-CTX,P1NP有明显相关性。在骨量正常的绝经后妇女中,在MGP m RNA与其他参数之间没有发现明显的相关性。3、PMOP组血清Fetuin-A、MGP、腰椎BMP2、Runx2 m RNA表达明显低于非骨质疏松组,而腰椎MGPm RNA表达高于非骨质疏松组(P0.05);两组间比较,血清BMP2、RUNX2水平、腰椎Fetuin-A m RNA表达没有明显的差异(P0.05)。多元逻辑回归分析显示,腰椎MGP、BMP2及RUNX2 m RNA表达与BMD相关(分别是OR 1.016,95%CI0.809-0.991,P=0.029;OR1.230,95%CI1.063-1.424,P=0.015;OR 1.107,95%CI1.016-1.205,P=0.048)。免疫组织化学结果显示,骨小梁周边的成骨细胞及骨髓基质细胞胞浆均可见Fetuin-A、BMP2、RUNX2、MGP的阳性表达,骨小梁周边的破骨细胞还可见到MGP的阳性表达。与非骨质疏松组相比,PMOP组MGP的光密度值水平较高(P0.05)而BMP2和RUNX2水平较低(P0.05或P0.01);两组间比较,Fetuin-A光密度值水平差异不明显(P0.05);4、同治疗前相对比,B、C两组都能有效改善患者的临床症状、增加患者腰椎及股骨颈的骨密度、提高血清Fetuin-A及MGP的水平(P0.05),对骨代谢标志物影响不明显(P0.05);其中C组能更快缓解疼痛,且对腰椎骨密度的升高效果更为显著(P0.01)。与治疗前比较,A组对各项指标影响均不显著(P0.05)。结论1、临床与试验研究提示,MGP与PMOP有一定的相关性,而FMC很可能通过影响骨矿化从而影响PMOP的发病;补肾中药治疗PMOP有中医的理论基础,也有现代试验研究的支持。2、低血清MGP m RNA水平可能与PMOP的发病有关,而雌激素参与对血清MGP的调控。3、血清FMC的合成减少及MGP在局部骨组织聚集,可能通过影响BMP2/Smad/Runx2信号通路,抑制正常的骨矿化,从而影响PMOP的发生。4、中药淫羊藿能够改善PMOP肾阳亏虚证患者的临床症状,增加BMD,并且其效果跟用药剂量呈相关,其作用机制可能与增加血清FMC的合成有关。
[Abstract]:Objective to summarize the pathogenesis of postmenopausal osteoporosis (PMOP) from a theoretical point of view, and to explore the relationship between matrix Gla protein (MGP) and bone metabolism in PMOP patients and A- matrix Gla protein calcium phosphate mineralization complex (FMC) involved in the pathogenesis of PMOP from the perspective of clinical research, and to observe the treatment of PMOP patients (kidneys) with Epimedium capsule (Epimedium capsule). The clinical curative effect and mechanism of action of Yang deficiency syndrome). Method 1, theoretical study: consult the literature, summarize the pathogenesis of PMOP, analyze the relationship between the abnormal bone mineralization and the PMOP, review the relevant literature of ancient and modern, in order to understand the understanding of the etiology, pathogenesis and treatment of PMOP, and provide the theoretical basis for the clinical trial. 2, the correlation between serum matrix Gla protein and bone metabolism: This study entered 120 patients with PMOP and 60 postmenopausal women with normal bone mass. The serum MGP m RNA level was detected by polymerase chain reaction (PCR), bone state was evaluated by bone density (BMD) and bone conversion markers (beta -CTX, P1NP). Serum estradiol (E2), parathyroid hormone was also detected. (PTH) the mechanism of blood calcium (Ca), blood phosphorus (P) level.3, fetal globulin A- matrix Gla protein calcium phosphate complex (FMC) involved in PMOP: 23 cases of PMOP patients and postmenopausal women with normal bone mass were selected for the operation of lumbar vertebrae, and some of the lumbar vertebrae were taken during the operation, and the serum fetal globulin A (fetuin A), matrix protein, and bone morphogenesis Protein 2 (BMP2), runt related transcription factor 2 (RUNX2) level was detected by enzyme linked immunosorbent assay (ELISA). The local fetuin A, MGP, BMP2, RUNX2 m RNA and protein expression were detected by PCR and immunohistochemical methods respectively. 90 patients were selected and randomly divided into placebo control group (placebo control group). The low dose group of Epimedium capsule and C group (high dose group of Epimedium capsule) were treated for 24 weeks. Before and after 24 weeks of treatment, the pain VAS score, main syndrome score, TCM syndrome integral effect change, and the changes of BMD, serum PINP, beta -CTX and serum Fetuin-A, MGP level were detected. Statistical analysis: data analysis The treatment was carried out using the statistical software SPSS 20. All the data were expressed in the form of mean mean standard deviation (x + s). The statistical results showed that the difference was statistically significant. Results 1. The results showed that the abnormal bone mineralization was one of the causes of OP/PMOP, and the formation of FMC was an important mechanism for maintaining normal bone mineralization, but F It is not clear how MC participates in the pathogenesis of OP/PMOP; traditional Chinese medicine believes that the key to the pathogenesis of OP/PMOP lies in the deficiency of kidney marrow caused by many reasons, and it is related to weakness of the spleen and stomach, insufficiency of liver blood and stasis of blood. In addition, my tutor, professor Xiang Nan, is also an important factor in the pathogenesis of OP. In this case, OP/PMOP is also based on kidney tonifying and kidney tonifying. The difference in BMD, MGP m RNA, beta -CTX, P1NP (P0.05).PMOP patients was significantly lower than that of the control group (P0.05).PMOP patients (0.835 + 0.415, 4.524 + 0.769, PMOP). R=0.227, P=0.013) was positively correlated. No MGPm RNA was found to be associated with age, height, weight, PTH, Ca, P, and beta -CTX, and P1NP had a significant correlation. The expression of MGPm RNA in the lumbar spine was higher than that in the non osteoporosis group (P0.05), and there was no significant difference between the two groups, the serum BMP2, the RUNX2 level, and the Fetuin-A m RNA expression (P0.05). 015; OR 1.107,95%CI1.016-1.205, P=0.048). The immunohistochemical results showed that the cytoplasm of osteoblasts and bone marrow stromal cells around the bone trabeculae showed Fetuin-A, BMP2, RUNX2, MGP positive expression, and the positive expression of MGP in the osteoclasts around the trabecular bone. Compared with the non osteoporotic group, the optical density of MGP in the PMOP group was more than that of the non osteoporotic group. High (P0.05) and BMP2 and RUNX2 levels were lower (P0.05 or P0.01); compared with the two groups, the difference of Fetuin-A light density level was not obvious (P0.05); 4, compared with before treatment, B, C two groups could effectively improve the patient's clinical symptoms, increase the bone density of the lumbar and femoral neck, increase the level of serum Fetuin-A and MGP (P0.05), and bone metabolic markers. The effect was not obvious (P0.05), of which group C could relieve pain faster and increase the effect of lumbar bone density more significantly (P0.01). Compared with before treatment, group A had no significant influence on various indexes (P0.05). Conclusion 1, clinical and experimental studies suggest that MGP has a certain correlation with PMOP, and FMC is likely to affect PMOP by affecting bone mineralization. The treatment of PMOP has the theoretical basis of traditional Chinese medicine and the support of modern experimental research. The level of the low serum MGP m RNA may be related to the pathogenesis of PMOP, while estrogen participates in the regulation of the serum MGP, the decrease of serum FMC and the accumulation of MGP in the local bone tissue can affect the BMP2/Smad/Runx2 signaling pathway and inhibit normal. Bone mineralization affects the occurrence of.4 in PMOP. The Chinese herb Epimedium can improve the clinical symptoms of the patients with PMOP deficiency syndrome and increase the BMD, and the effect is related to the dosage of the drug. The mechanism of its action may be related to the increase of the synthesis of serum FMC.

【学位授予单位】：湖北中医药大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R259

【参考文献】