免疫炎性疾病新认识及中西医结合临床对策于清宏2014913沈阳

1、免疫炎性疾病新认识及中西医结合临床对策免疫炎性疾病新认识及中西医结合临床对策南方医科大学珠江医院风湿免疫科于清宏2014年9月13日沈阳非可控性炎症非可控性炎症免疫炎性疾病病的共同通道免疫炎性疾病病的共同通道A cellular, immune and metabolic response to injury and infectionDefinition of inflammation炎症定义炎症定义Inflammation is a two-edged sword serves as a protective response, but is often a major cause of

2、tissue damage in infectious, immunologic, and vascular diseases, as well as after trauma. 红肿热痛功能红肿热痛功能障碍障碍促炎促炎/ /抗炎细胞抗炎细胞因子平衡因子平衡炎症是一个炎症是一个程序化过程程序化过程炎症细胞表型炎症细胞表型转变转变Heredity, Nonresolving inflammation and autoimmune diseases先天禀赋外感内伤证候部分自身免疫性疾病部分自身免疫性疾病免疫介导的炎性疾病免疫介导的炎性疾病 Chronic diseases with promine

3、nt inflammation, often caused by failure of tolerance or regulation RA, IBD, MS, psoriasis, many others Affect 2-5% of people, incidence increasing May result from immune responses against self antigens (autoimmunity) or microbial antigens (Crohns disease?) May be caused by T cells and antibodies Ma

4、y be systemic or organ-specific自身免疫病理过程自身免疫病理过程Susceptibility genesEnvironmental trigger(e.g. infections, tissue injury)Failure ofself-toleranceActivation ofself-reactive lymphocytesImmune responses against self tissuesPersistence of functionalself-reactive lymphocytesActivationEffector T cellsNorma

5、l: reactions against pathogensInflammatorydisease, e.g. reactions against self ToleranceRegulatory T cellsNo response to selfControlled response to pathogens 淋巴细胞活化及控制的平衡淋巴细胞活化及控制的平衡阳阳阴阴自身免疫的遗传背景自身免疫的遗传背景 Human autoimmune diseases are complex polygenic traits Identified by genome-wide association ma

6、pping Single gene mutations are useful for pathway analysis Some polymorphisms are associated with multiple diseases May control general mechanisms of tolerance and immune regulation Other genetic associations are disease-specific May influence end-organ damage NOD2: polymorphism associated with 25%

7、 of Crohns disease Microbial sensor PTPN22: commonest autoimmunity-associated gene; polymorphism in RA, SLE, others Phosphatase CD25 (IL-2R ): associated with MS, others; genome-wide association mapping Role in Tregs自身免疫遗传背景自身免疫遗传背景: : 最近发现最近发现感染与自身免疫感染与自身免疫 Infections trigger autoimmune reactions C

8、linical prodromes, animal models Autoimmunity develops after infection is eradicated (i.e. the autoimmune disease is precipitated by infection but is not directly caused by the infection) Some autoimmune diseases are prevented by infections (type 1 diabetes, multiple sclerosis, others? - increasing

9、incidence in developed countries): mechanism unknown The “hygiene hypothesis”主要免疫反应类型决定疾病自然病程主要免疫反应类型决定疾病自然病程 Th1 response: inflammation, autoantibody production; autoimmune diseases Th2 response: IgE+eosinophil-mediated inflammation; allergic reactions Th17 response: acute (and chronic?) inflammati

10、on; increasingly recognized in immune-mediated diseasesTh1 cells (IFN-g g)Th2 cells (IL-4, IL-5)Th17 cells (IL-17)Nave CD4T cellCD4 细胞亚群细胞亚群: 产生及功能产生及功能 Regulatory T cellsIFN-g g, IL-12:T-bet, Stat4IL-4:GATA3, Stat6TGF- + IL-6:RORg gt, Stat3TGF-IL-2:Foxp3, Stat5Host defense: many microbesSystemic an

11、d organ-specific autoimmune diseasesHost defense: helminthsAllergic diseasesHost defense: fungi, bacteria Organ-specific autoimmune diseases After a microbial infection, activa-ted microbe-speci-fic TH1 (mTH1) cells migrate to the infected organ. A. Molecular mimicry. B. Epitope spre-ading. C. Bysta

12、nder activation. D. Cryptic antigen.部分隐蔽抗原部分隐蔽抗原器官特异性自身免疫病理器官特异性自身免疫病理Current therapies target late stages of the reaction (lymphocyte activation, inflammation).Ultimate goal should be to tackle the underlying cause and restore control of the abnormally directed response 免疫炎性疾病代表疾病类风湿关节炎?脊柱关节炎?血管炎?类

13、风湿关节炎免疫炎症机制研究状况类风湿关节炎免疫炎症机制研究状况HLA表型与等位基因变异检测表型与等位基因变异检测类风湿关节炎相关类风湿关节炎相关HLA-DR4结合表位结合表位RA相关共享表位氨基酸序列相关共享表位氨基酸序列 Car accident Cancer RA HPN AS Hemophilia 多基因疾病多基因疾病脊柱关节炎免疫炎症机制研究现状脊柱关节炎免疫炎症机制研究现状 强直性脊柱炎的易感基因强直性脊柱炎的易感基因Nature Genetics 2013;45(7):730-8 IBD / subclinical ileitisHLA-B27excess IL-23Excess

14、IL-23R sensitivity (SNPs)The IL-23R+ spondyloarthropogenic cellCua and Sherlock, Nat Med. 2011 Sep 7;17(9):1055-6.Sherlock JP, et al. Nat Med. 2012;18:106976ERAP1 associated with HLA-B27+ve ASNature Genetics 2011;43:761-767Picture courtesy of Dr. Eric ReitsERAP1/ERAP2 process antigenic peptide epito

15、pes before loading onto HLA-B27Nucleus NK/MoDCImmunoreceptor Recognition of Aberrant B27CD8+Arthritogenic Peptides and Autoreactive T CellsERBiPUPRB27 Misfolding,ER Stress, and UPR ActivationNo defining mechanism by which HLA-B27 causes ASAltered APC FunctionCD4+ERAP2 SNP N392K affects both enzyme a

16、ctivity and specificity The kcat of the enzyme changes by 25-foldEffects on trimming rate are substrate-specific!Vanhille et al. Molecular Genetics & Genomic Medicine 2013; 1(2): 98107 Evnouchidou et al. J Immunol 2012; 189(5):2383LSRHHAFSFR peptideREF528R730Q0100200300Ki, mMERAP1 SNPs at positi

17、ons 528 and 730 affect both enzyme activity and antigen presentationkcat/KMKiMHCI levelsEvnouchidou et al. J Immunol 2011LG10LLG9LLG8LLG7LLG6LLG5LLG4LLG3LLG2L051015ERAP1 KQSpecific activity (pmol/ (h*ng)Length selection can be altered by polymorphic variationGarcia et al. MCP, 2012LG10LLG9LLG8LLG7LL

18、G6LLG5LLG4LLG3L0200400600800LAPSpecific activity (pmol/ (h*ng)Affects activityAffects SpecificityEvnouchidou et al. J Immunol 2012; 189(5):2383SNPs are “scattered” all over the protein structureAS易感基因的贡献值肠道菌微生态与免疫炎性疾病ASCDHCBacteroidesAcintobacteriaFirmicutesFusobacteriaProteobacteriaAS gut microbiom

19、e is different to CD and HCASCDHCBacterial control机械压力的骨赘形成的作用机械压力的骨赘形成的作用Ann Rheum Dis 2013遗传和环境因素共同导致疾病的发生Nature Med 2012;18:1018IL23介导的T细胞参与了AS的致病 ？ ？ ？ ？ ？强直性脊柱炎的致病机理假说IL-17IL-1IL-6TNF-Figure 3 Nature 2014Connection of biological RA risk genes to drug targets Scher et al. eLife 2013;2:e01202. DO

20、I: 10.7554/eLife.01202Prevotella copri correlates with enhanced susceptibility to arthritis血管炎发病机制研究现状血管炎发病机制研究现状免疫学新进展- 免疫系统免疫系统4-96 hours96 Hours laterPost InfectionInnateAdaptiveTarget Cell+Nave T Th-1 Th-2 Th-17 Treg TGF- TGF- IL-6/23 IL-4 IFN-IL-12 CD28TCRB CellAntiboddyIFN-IL-12 MacrophageNK c

21、ellDCEpithelial cellCell immunity Humoral immunityInflammationImmunosuppression IFN-TNF- IL-4,5.13IL-17,6TNF- TGF-Eosinophil Basophil Mast CellNeutrophil T cellNKT cellCD8+T cell创新点选择-免疫学新进展免疫学新进展-应答类型应答类型肠道上皮细胞的正常屏障作用肠道上皮细胞的正常屏障作用Microbial recognition promotes IEC health and functionNature Review I

22、mmunology, 2013, 13:75-87新的免疫细胞新的免疫细胞-ILC（innate Lymphoid cells)模式识别受体（pattern recognition receptors, PRRs):TLRs,NLRnudeotide oligmerization domain（NOD）-like receptors, NLRsCARD: Caspase activation and recruitment domainASC: Apoptosis-associated speck-like protein containing CARD 5/2/2022NOD-like re

23、ceptors, NLRsNLRP3植物药抗炎机制研究举例植物药抗炎机制研究举例调节免疫功能紊乱 TGPT cellTh/Ts细胞比值 Bcell巨噬细胞TNF- IL-1 LTB4 活性氧类 免疫调节肝损伤小鼠 免疫性关节炎大鼠 系统性红斑狼疮小鼠 Wei W et al, Int Immunophar, 2002,2005,2009梁君山，魏伟，等梁君山，魏伟，等. 中国药理学通报，中国药理学通报，1989,5:354-357 王兴旺，魏伟，等王兴旺，魏伟，等. 中国药理学通报，中国药理学通报，1990,6:363-366 周玲玲，魏周玲玲，魏 伟，等伟，等 .中国药理学通报，中国药理学通

24、报，2002,18:175-177 白芍总苷机理研究白芍总苷机理研究OOOHOHOHCH2OHCH3OHOHOCCOOCH3HTGP ？TGP是否能够作用与DC及相应后果？DC分化发育和成熟分化发育和成熟MDP：Lin- CX3CR1+ CD11b- CD115+ cKit+ CD135+CDP：Lin- CD115+ Flt3+ CD117loFlt3：FMS样酪氨酸激酶样酪氨酸激酶3， (Flt3L，配体，配体)imDCmDCTGP白芍总苷（白芍总苷（total glucosides of paeonia，TGP）OOOHOHOHCH2OHCH3OHOHOCCOOCH3HOVA免疫免疫明确

25、现象明确现象-TGP抑制免疫应答抑制抑制T T细胞活化增殖细胞活化增殖抑制机体对于抑制机体对于新新入侵抗原的免疫应答入侵抗原的免疫应答探讨关键表型探讨关键表型-TGP抑制DC成熟被动转移实验：被动转移实验：mDC恢复小鼠对于OVA反应证实证实TGP抑制抑制DC成熟而导致免疫应答降低成熟而导致免疫应答降低探讨机理探讨机理-TGP抑制TLR-MyD88/NF-kB活化*MyD88与疾病治疗-RA-CIA模型CII+CFACII+IFA OOOHOHOHCH2OHCH3OHOHOCCOOCH3H细胞亚群、细胞因子、信号转导细胞亚群、细胞因子、信号转导n=10/组3次重复16分评分DBA1明确现象-T

26、GP延缓和减轻CIA发病与炎症 提前使用提前使用TGP，延缓并减轻，延缓并减轻CIA发病发病机理-TGP抑制DC成熟 降低CII免疫应答 明确表型-TGP降低Th1/Th17细胞亚群和功能临床验证临床验证- -TGP降低RA患者Th1/Th17 TNFa产生细胞减少PSA? TGP?TGP作用后作用后PSA样小鼠体内样小鼠体内M1细胞活性降低细胞活性降低TGP 抑制M1，上调M2（体外）The Novel Role of Total Glucosides of Paeony in Regulating Type I and II Macrophages Activities in vivo a

27、nd in vitro, Experimental Dermatology, 2014, in revision TGP干扰TLR4与LPS结合，阻断信号转导Int Immunophar,2012,12:275-82 TLR4和和TGPTLR4-MD2-LPS Complex (Nature 2009)TLR4-LPS结合部位TLR4和TGPOOOHOHOHCH2OHCH3OHOHOCCOOCH3H免疫炎性疾病治疗现状免疫炎性疾病治疗现状糖皮质激素作用机制糖皮质激素作用机制糖皮质激素受体（糖皮质激素受体（GCR） 有核细胞都有有核细胞都有GCR直接或间接影响基因转录直接或间接影响基因转录 10

28、-100个基因具有个基因具有GC反反应元素（应元素（GC response element送，送，GCE） 直接抑制直接抑制NF-kB,抑制细抑制细胞因子产生胞因子产生 间接抑制间接抑制NF-kB 、I-kB影响转录后过程影响转录后过程 mRNA翻译、蛋白质合成翻译、蛋白质合成、蛋白质分泌、蛋白质分泌抑制促炎因子抑制促炎因子 IL-1、IL-6、IL-13、GM-CSF、TNF-a减少炎症部位白细胞聚集减少炎症部位白细胞聚集 通过抑制促炎症因子、通过抑制促炎症因子、 NF-kB抑制黏附分子抑制黏附分子 E-selectin、VCAM-1、ICAM-1抑制烷酸产物抑制烷酸产物 如白三烯（如白三烯

29、（leukotriene）降低血管渗透性降低血管渗透性皮质类固醇皮质类固醇 抗炎作用抗炎作用 相当剂量相当剂量 盐皮激效应盐皮激效应 药理药理T1/2T1/2 血浆血浆T1/2T1/2 h h min氢化可的松氢化可的松 1 20 2 812 90 可的松可的松 0.8 25 2 812 30强的松强的松 3.5 5 1 1236 60强的松龙强的松龙 4 5 1 1236 200甲强龙甲强龙 5 4 0 1236 180曲安西龙曲安西龙 5 4 0 2448 300 地塞米松地塞米松 30 0.75 0 3654 100 300 倍他米松倍他米松 25 0.80 0 3654 100 300

30、 氯地米松氯地米松 40 0.50 0 全身性应用皮质类固醇的当量比较 糖皮质激素全身应用副作用糖皮质激素全身应用副作用内分泌系统内分泌系统抑制肾上腺抑制肾上腺抑制生长、儿童性成熟延迟抑制生长、儿童性成熟延迟体重增加、柯兴貌体重增加、柯兴貌糖尿病糖尿病代谢紊乱代谢紊乱低血钾症、高血糖、高血脂低血钾症、高血糖、高血脂骨骼肌肉系统骨骼肌肉系统骨质疏松、椎骨压缩性骨折骨质疏松、椎骨压缩性骨折骨无菌性坏死（髋、肩、膝）骨无菌性坏死（髋、肩、膝）肌病（急性或慢性）肌病（急性或慢性）皮肤皮肤皮肤变薄皮肤变薄紫纹紫纹痤疮痤疮多毛多毛眼眼白内障白内障青光眼青光眼免疫系统免疫系统IgG降低降低丧失延迟性过敏反应

31、丧失延迟性过敏反应感染增加感染增加 心血管系统心血管系统高血压高血压动脉粥样硬化动脉粥样硬化血液系统血液系统淋巴细胞减少淋巴细胞减少嗜酸细胞减少嗜酸细胞减少中性粒细胞增加中性粒细胞增加精神精神/神经神经情绪反常情绪反常精神分裂精神分裂免疫抑制剂类型免疫抑制剂类型 Calcineurin inhibitors Cyclosporine Tacrolimus Purine synthesis inhibitors Azathioprine Mycophenolate mofetil Nonspecific prednisoneTarget of Rapamycin inhibitor Siroli

32、musPolyclonal antibodies (bind several CDs) Thymoglobulin Atgam Monoclonal Antibodies Blocks IL-2 receptor Daclizumab Basilixmab OKT3 (anti-CD3)IL-2RG0G0G1SG2/MG1/0T-cellSTEROIDCTLA-4-FcFUSION PROTEINU. V.CYCLOSPORINFK506STEROIDRAPAMYCINAZATHIOPRINE(6MP)METHOTREXATEMIZORBINEMYCOPHENOLICBREQUINARCYCL

33、OSPHOSPHAMIDEX-RAYSActivationby antigenIL-2responseDNAsynthaseMitosisANTI: TCRCD3CD4/8CD45RBLFA-1ICAM1ANTI-IL-2RTOXINSIL-2RCytokinesynthesisTherapeuticmonoclonalsDrugs and othertreatments部分免疫抑制剂转环节部分免疫抑制剂转环节Reduce inflammation TNF-alpha blockers (RA, Crohns dis., psoriasis)e.g., Enbrel, Remicade, Hu

34、mira IL-1 receptor antagonist (RA) Abs against IL6R and IL-15R Statins, shown to lower CRP (RA, MS) Rituxin = monoclonal Ab = anti-CD20Eliminates B cells in non-Hodgkins lymphoma (maybe also RA, and other Ab-mediated autoimmune diseases) 免疫炎性疾病生物制剂治疗其他可能的治疗通道T cell vaccines (against activated Ag-spe

35、cific T cells)Interfere with antigen presentation (anti-MHC)Monoclonal antibodies against a variety of target antigensOral induction of tolerance (MS) So far, efforts have been more successfulin mice than humans其他可能的治疗通道中西医结合抗炎机制研究思路中西医结合抗炎机制研究思路 炎症的消退是多个协同作用的结果；炎症的消退是多个协同作用的结果； 多机制通道可以恢复细胞环境；多机制通道可

36、以恢复细胞环境； 内源性抗炎因子产生的机制有待深入研究；内源性抗炎因子产生的机制有待深入研究； 调节炎症产生的环境是新的治疗选择调节炎症产生的环境是新的治疗选择 。中药抗炎药物应用的思路中药抗炎药物应用的思路如何调节炎症产生的环境？如何调节炎症产生的环境？ 氧化应激和自由基；氧化应激和自由基； 氧化氧化-抗氧化状态的不平衡；抗氧化状态的不平衡； 氧化氧化-抗氧化的再平衡。抗氧化的再平衡。中药抗炎药物应用的思路中药抗炎药物应用的思路 植物抗氧化剂植物抗氧化剂:安全和有效的慢性抗炎药物安全和有效的慢性抗炎药物? 炎症介质、促炎的细胞因子和自由基产生的复杂机制。炎症介质、促炎的细胞因子和自由基产生的

37、复杂机制。 植物药物中和自由基，而不破坏细胞存在的生物环境机制。植物药物中和自由基，而不破坏细胞存在的生物环境机制。天然抗炎药物应用的思路天然抗炎药物应用的思路抗炎中药优势设想：抗炎中药优势设想：第一、多通道阻断炎症介质产生；第一、多通道阻断炎症介质产生；第二、多成分低浓度调节局部环境；第二、多成分低浓度调节局部环境；第三、整体温和作用和动员机体本身的抗炎机制调节环境第三、整体温和作用和动员机体本身的抗炎机制调节环境第四、增强抗炎能力、防止组织损伤同时不会因过分强烈的作用干第四、增强抗炎能力、防止组织损伤同时不会因过分强烈的作用干扰正常的细胞信号和免疫反应，抑制内源性的抗炎信号通道。扰正常的细胞信号和免疫反应，抑制内源性的抗炎信号通道。中药抗炎药物应用的思路中药抗炎药物应用的思路1）激素、