者高迁移率族蛋白B1水平变化的临床研究(11年8月微循环杂志发表).doc

冠心病患者高迁移率族蛋白B1水平变化的临床研究武汉市第五医院心内科 盛蕾 伍琼目的: 炎症反应与冠心病（CHD）的形成和复发相关。以往研究证明高迁移率族蛋白B1（HMGB1）是心血管疾病中新的促炎因子。本研究旨在探讨CHD患者血清HMGB1水平是否升高及其意义。方法: 本研究纳入连续收集的CHD患者158例，选择30例年龄和性别匹配的无冠心病体检者作为对照组，采用ELISA法检测两组人群血清HMGB1水平。结果: CHD患者血清HMGB1水平较对照组显著增高（8.622.18 ng/ml vs 2.220.63 ng/ml，P0.05；8.622.18 ng/ml vs 5.291.43 ng/ml，p0.05）。急性冠脉综合征（ACS）患者血清HMGB1水平较稳定型心绞痛患者显著升高（5.291.43 ng/ml vs 2.220.63 ng/ml， p均0.05）。CHD患者血清HMGB1水平与hs-CRP水平呈显著正相关（n=88，r=0.629，p0.05）。结论 本研究提示CHD患者血清HMGB1水平均显著增高，其表达与hs-CRP表达水平呈显著正相关。关键词: 高迁移率族蛋白B1；冠心病；炎症The expression and significance of HMGB1 in patients with coronary heart diseaseObjective: Inflammatory process is associated with the development and recurrence of coronary heart disease (CHD). High mobility group box 1 protein (HMGB1) has been proved to be as a novel pro-inflammatory cytokine in cardiovascular diseases. This study investigated whether the serum HMGB1 level was increased in CHD patients. Methods: A total of 158 CHD patients were enrolled in this study. Thirty age- and sex-matched people without CHD were considered as control group. Serum HMGB1 concentration in CHD patients and healthy people was measured by ELISA. Results: HMGB1 level in CHD group (8.622.18 ng/ml) was higher than that in control group (2.220.63 ng/ml) (p0.05). HMGB1 level in ACS group was higher than that in SA group (p0.05). There was significantly positive correlation between HMGB1 level and hs-CRP level in CHD patients (n=88, r=0.629, p0.05). Conclusion: The present study showed that serum HMGB1 level was markedly increased in CHD patients, and was positive correlated with hs-CRP level.Key words: High mobility group box 1 protein; Coronary heart disease; Inflammation目前大量研究显示炎症过程和CHD发展及复发相关4。许多研究发现在CHD患者血清中一些促炎因子，如高敏C反应蛋白（hs-CRP）、肿瘤坏死因子-（TNF-）和白细胞介素-6（IL-6）等显著升高，这些促炎因子水平与CHD的发病风险呈正相关4-6。这些研究结果提示促炎因子可能在CHD发展和复发中发挥重要角色，可能是CHD的病理生理机制之一。高迁移率族蛋白B1（HMGB1）是一种非染色体核蛋白，可以调控基因转录和维持核小体结构稳定7。1999年Wang等8首次证实HMGB1在脓毒血症炎症反应中充当晚期炎症介质，抑制HMGB1可以减轻内毒素的致死效应，提示胞外HMGB1在脓毒血症的发病机制中发挥重要角色。最近研究表明在心血管疾病中HMGB1同样发挥着重要的促炎作用9,10。然而，CHD患者血清HMGB1是否升高目前尚不清楚。本研究旨在探讨CHD患者血清HMGB1水平变化及其与hs-CRP表达的关系。1材料与方法1.1 研究对象本研究收集我院连续入院的158例CHD患者，另外纳入30例年龄和性别与CHD组相匹配的于我院行身体检查为无CHD的人群作为对照组（均需满足排除标准）。其中CHD患者又分为急性冠脉综合征（ACS）组和稳定型心绞痛(SA)组，其诊断均符合WHO标准。所有研究对象均需采集详细病史，行体格检查、常规生化检查。排除标准包括：瓣膜性心脏病、6个月内手术或中风患者、感染病史、慢性炎症疾病、肝脏疾病、恶性肿瘤、慢性肾功能衰竭、自身免疫性疾病、甲状腺功能异常、电解质紊乱、服用抗炎药物如糖皮质激素和非甾体类抗炎药（阿司匹林除外）者。1.2 研究方法研究对象在空腹12h后在早上7-8点从肘前静脉抽取外周静脉血。血清标本等量分装后保存在-70冰箱。所有样品均一次性解冻使用。使用Hitachi 912分析仪（德国罗氏公司）按标准实验室技术检测血清hs-CRP。血清HMGB1水平则采用HMGB1 ELISA试剂盒（日本东京Shino-Test公司）按说明书操作检测。白细胞计数，高密度脂蛋白，低密度脂蛋白，总胆固醇等指标的检测在全自动生化分析仪上统一进行检测。2 结 果2.1 两组一般临床特征如表1所示， CHD组及对照组间性别、吸烟、饮酒、高血脂、高血压、糖尿病、体重指数（BMI）均无显著差异。表1 两组一般临床特征比较年龄(岁)男/女BMI(kg/m2)高血脂高血压糖尿病吸烟饮酒对照组(n=30)55.68.516/1423.73.2542108CHD组(n=158)57.59.685/7324.83.91221622132.2 各组HMGB1血清水平及有关指标的比较如表2所示，三组间HMGB1水平及hs-CRP水平有显著性差异（p0.05）。CHD组患者血清HMGB1水平（8.622.18 ng/ml）较对照组（2.220.63 ng/ml）和ACS组（5.291.43 ng/ml）显著升高（p均0.05）。阵发性CHD组患者HMGB1水平较对照组显著增高（p0.05）。持续性CHD组患者血清hs-CRP水平（4.201.04 mg/L）较对照组（0.980.32 mg/L）和阵发性CHD组（2.110.94 mg/L）显著升高（p均0.05）。阵发性CHD组患者hs-CRP水平较对照组显著增高（p0.05）。表2 各组血清HMGB1水平及有关指标表达hs-CRP（mg/L）HMGB1（ng/ml）WBC（109/L）对照组(n=30)0.980.322.220.636.081.42SA组(n=71)2.110.94#5.291.43#7.141.93ACS组(n=87)4.201.04#8.622.18#7.062.05#与对照组相比，p0.05；SA组相比，p0.05。2.3 HMGB1与心血管危险因子的相关性 如表3所示，CHD患者HMGB1水平与hs-CRP水平呈显著正相关（n=158，r=0.629，p0.05）。HMGB1水平与年龄和LAD也具有相关性，但和BMI、LVEDD、EF和WBC等无相关关系。表3 血清HMGB1水平与其他指标的相关性危险因素rp年龄0.2980.05LAD0.3520.05LVEF0.0920.05hs-CRP0.6290.053 讨论HMGB1可由坏死和损伤细胞被动释放或者由先天免疫细胞（如巨噬细胞和单核细胞）激活后主动释放7。现有研究表明HMGB1一旦从坏死细胞和巨噬细胞释放，可作为炎性因子刺激上调IL-6、 TNF-及巨噬细胞炎性蛋白-1（MIP-1）和MIP-1等表达7,14,15。本研究发现CHD患者血清HMGB1水平与hs-CRP水平呈正相关，而hs-CRP水平可作为CHD患者病情变化的重要预测因子6,16。这与以往研究结论一致10,11。Hu等10及Yan等17发现冠心病患者HMGB1水平与hs-CRP、TNF-和IL-6表达明显相关。这些发现提示HMGB1与其他促炎因子（包括CRP）存在密切关系，同时提示HMGB1可能是CHD患者预后的重要预测因子。Inoue等18研究显示人晚期动脉粥样硬化损伤中HMGB1来源于激活的血管平滑肌细胞，并且HMGB1可直接刺激CRP产生。同时Kawahara等19研究提示CRP可通过p38MAPK信号通路诱导HMGB1表达呈剂量依赖性。同时HMGB1可以触发炎性因子的表达，提示其可增强炎症反应7,14,18,19。这些研究提示HMGB1可能是CHD发病机理中关键的促炎因子。因此，CHD患者血清HMGB1上调，并可能与其他炎性因子共同参与CHD的病理生理机制4-6。HMGB1信号传导受体至少三种：晚期糖基化终末产物受体（RAGE）、Toll样受体-2（TLR2）和TLR4。RAGE信号途径可激活核因子B（NF-B）以及胞外调节蛋白激酶-1/2（ERK1/2）和p38MAPK信号通路，后者可促进细胞因子生成和细胞存活。而TLR2和TLR4信号途径可通过髓样分化因子88（MyD88）依赖机制激活NF-B通路13,14。胞外HMGB1可与炎症细胞表面RAGE或TLRs等受体结合，从而激活炎症相关的信号通路，触发一系列促炎因子释放，如TNF-、Ils、MIP-1和MIP-113,14，最终导致炎症反应循环增强。最近研究显示RAGE参与了糖尿病大鼠的心房结构重塑18。Kawahara等19发现CHD患者TLR2表达水平上升，提示HMGB1对CHD的作用可能通过增加HMGB1受体水平而增强。这些结果进一步提示HMGB1可能参与CHD发病机制。临床研究显示动脉粥样斑块中HMGB1及其受体RAGE表达增高，且HMGB1能通过与RAGE结合直接刺激血管平滑肌细胞产生C反应蛋白和金属基质蛋白，促进粥样斑块形成。因此，HMGB1可能是预防和治疗动脉粥样硬化的一个靶点。参 考 文 献1 Furberg CD, Psaty BM, Manolio TA, et al. 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