医学课件抗肾小球基底膜GBM病

1、抗GBM病的背景抗GBM病：循环中出现抗GBM抗体、脏器中沉积为特征的自身免疫病1919: Goodpasture首先报道1例18岁男性病人，咯血、急性肾衰竭主要累及肺和肾脏：Goodpasture病内科危重症：危及生命80%就诊时已进入尿毒症（ESRD）Goodpasure EM. Am J Med Sci 1919;158: 863-870Cui Z, Zhao MH. Nat Rev Nephrol. 2011 Dec 7:697-706抗GBM病的背景抗GBM病：循环中出现抗GBM抗体、脏器中沉少见病：1-2/百万人口本研究所：累计诊断500余例国际上最大的临床资源库治疗依赖血浆置换：

2、昂贵，但多为时已晚抗GBM病仍然是我国内科医生的重大挑战抗GBM病的发生情况 Cui Z, Zhao MH. Nat Rev Nephrol. 2011 Dec 7:697-706少见病：1-2/百万人口抗GBM病仍然是我国内科医生的重大抗GBM病研究现状Hudson GB. Vanderbilt UniversityGBM molecular architecture of conformational epitopesPusey CD. HammersmithImperial College LondonPE in anti-GBM diseaseWKY rat modelGenetics

3、 of EAG modelsSegelmark M & Wieslander JLund UniversityRecombinant antigensDetection of anti-GBM diseaseZhao MH & Cui ZPeking UniversityHuman anti-GBM diseaseLinear epitopesMolecular mimicryKitching AR. Monash University.MHC and T cell activationAnimal modelsLou YH. University of TexasT cell epitope

4、Animal model抗GBM病研究现状Hudson GB. Pusey CD. 抗GBM病是典型的自身免疫病靶抗原3(IV)NC1 （肺、肾）EpitopeEa和Eb-构象性Saus J, et al. J Biol Chem 1988;15;263:13374-80Salant DJ. N Engl J Med 2010;363;4:381-391抗GBM病是典型的自身免疫病靶抗原Saus J, et al抗GBM病的科学问题病因表型差异病因遗传易感背景自身免疫T细胞B细胞3(IV)NC1表型？免疫耐受？诱发因素？5抗GBM病的科学问题病因病因遗传易自身T细胞B细胞3(IV抗GBM病的科

5、学问题病因表型差异肾受累轻重1/3合并ANCA少数合并MN病因遗传易感背景自身免疫T细胞B细胞3(IV)NC1表型？免疫耐受？诱发因素？6抗GBM病的科学问题病因病因遗传易自身T细胞B细胞3(IV23/M间断咯血 4 个月，加重1个月HGB: 71g/L; PO2 58mmHg; Scr 94.0 mol/l尿常规: protein (+), RBC 5-8/HPF血清抗GBM抗体 (+), ANCA (-)肾活检: IgG沿GBM线样沉积,肾小球轻微病变治疗：Pred 1 mg/kg/d x 8w, 无PE和CTX随访7年肾功能正常Cui Z, et al. Kidney Int 2007;

6、72:1403-8 肾受累轻患者介于正常人与重症患者之间？转换机制？723/MCui Z, et al. Kidney Int 2既往：健康人血清无抗GBM抗体发现天然抗GBM抗体：中国和瑞典：各10名献血员IgG成分-亲和层析“阴性选择”？如何发展成致病性抗体？Cui Z, et al. Kidney Int 2006:69:894-9Cui Z, et al. Kidney Int 2010;78:590-7Natural anti-GBM ab既往：健康人血清无抗GBM抗体Cui Z, et al. K抗GBM抗体如何转变成致病性？天然抗GBM抗体Anti-GBM (+)严重肾受累Ant

7、i-GBM (+)正常肾功能正常人病人A病人 CIntra-moleculeEpitope spreading3, 4 1、2、3、4和5Subclass switchingIgG2、IgG4IgG1、IgG2、IgG3和IgG4治疗个体化T细胞调控3 Ea、 Eb3内其他位点Anti-GBM (+)轻度肾受累病人BCui Z, et al. Kidney Int 2006;69:894-9.Yang R, et al. J Am Soc Nephrol 2007;18(4):1338-43.Cui Z, et al. Kidney Int 2007;72(11):1403-8.Zhao J

8、& Cui Z, et al. Kidney Int. 2009;76:1108-15.Cui Z, et al. Kidney Int 2010;78(6):590-7.Chen JL & Hu SY, et al. Clin J Am Soc Nephrol. 2013;8(1):51-8.Inter-moleculeEpitope spreading抗GBM抗体如何转变成致病性？天然抗GBM抗体Anti-GB NATURE REVIEWS | NEPHROLOGY Cui Z, Zhao MH. Nat Rev Nephrol. 2011 Dec;7:697-706. Cui Z, Zh

9、ao MH. Nat Rev Nephro抗GBM病的科学问题病因表型差异肾受累轻重1/3合并ANCA少数合并MN病因遗传易感背景自身免疫T细胞B细胞3(IV)NC1表型？免疫耐受？诱发因素？抗GBM病的科学问题病因病因遗传易自身T细胞B细胞3(IV抗GBM病合并MN个例报道MN GBM damage：释放3 抗GBM 病抗GBM病足细胞损伤：表达M-PLA2R MN12抗GBM病合并MN个例报道128 patients with MN and anti-GBM diseaseSequential or simultaneousBetter prognosisAnti-3 (+): narro

10、w antigen spectrumAnti-PLA2R (-)Jia XY, et al. Kidney Int2014 Apr;85(4):945-528 patients with MN and anti-GB抗GBM病的科学问题病因易感性：HLA？诱发因素病因表型差异病因遗传易感背景自身免疫T细胞B细胞3(IV)NC1表型？免疫耐受？诱发因素？抗GBM病的科学问题病因病因遗传易自身T细胞B细胞3(IV抗GBM病的免疫学发病机制?Linear toConformational涉及感染、抗原递呈、抗原决定簇扩展、分子模拟15抗GBM病的免疫学发病机制?Linear涉及感染、抗原递呈、Bac

11、kground ( HLA )HLA geneLocation: CHR 6p21.3Classical HLA gene MHC class II molecular: Distribution : DCs、B cells、MStructure: hetero-dimerrecognized by CD4+ T cell Ag processed 、presentation MHC & disease: MS、RA、IDDM、 SLE et al. Background ( HLA )HLA gene(Rees, Kid Int, 1999)Dominantly protective all

12、eles DR1 and DR7No gene dosage effectMHC II dominant protectionHLA-DRB1*01:01 generates 3136-146 specific regulatory T cells.HLA-DRB1*15:01 generates 3136-146 specific effector T cell precursors.In HLA-DRB1*15:01x01:01 mice, 3136-146 specific effector T cell precursors are dominantly suppressed by 3

13、136-146 specific regulatory T cellsRees et al, Kidney Int 1999 Ooi et al, J Am Soc Nephrol 201317(Rees, Kid Int, 1999)DominantlDRB1*1501 allele：p=1.597107 DRB1*0404 allele：p=0.037 Patients with DRB1*1501 or *0404 had more crescent formation. (p=0.021).Yang R. et al. Clin Immunol 2009;133:245-250DRB1

14、*1501 allele：p=1.597107 Association of HLA alleles (4 digits, P3.55E-4)AlleleCase_freControl_freORP_valDRB1*15010.43840.14694.5495.658E-28DQB1*06020.38400.15443.3362.032E-17DQA1*05020.0255470.000834730.696.987E-7DQB1*03030.04710.14440.28858.575E-6DRB1*09010.065220.14940.39111.611E-4Determine the sig

15、nificantvariation marker of genotypeCase: 138 vs. Control: 599rs41541412: the only significant SNP, belongs to DQA1*0502 nonsense mutation, change the 82th AA of DQ polypeptide. CHRSNPCaseControlCHISQP-valOR632609249.C0.02550.00083524.626.99E-730.69632609249.G0.02550.00083524.626.99E-730.69Associati

16、on of a novel HLA SNP(P3:Confirmed linkage. LOD-2: No linkage. LOD=0: the possibility is equal Linkage analysis among the significant allelesUnpublished dataAllele-1Allele-2Dr2LOD scoreD抗GBM病的科学问题病因易感性诱发因素：环境？病因表型差异病因遗传易感背景自身免疫T细胞B细胞3(IV)NC1表型？免疫耐受？诱发因素？抗GBM病的科学问题病因病因遗传易自身T细胞B细胞3(IV抗GBM病的科学问题病因易感性诱发

17、因素病因：感染？表型差异病因遗传易感背景自身免疫T细胞B细胞3(IV)NC1表型？免疫耐受？诱发因素？23抗GBM病的科学问题病因病因遗传易自身T细胞B细胞3(IV假说：微生物可能是抗GBM病的病因之一1919: Goodpasture首先报道1例18岁男性病人，咯血、急性肾衰竭流感？60%的患者发病前有前驱感染症状病原微生物-分子模拟?Goodpasure EM. Am J Med Sci 1919;158: 863-870分子模拟B细胞表位T细胞表位24假说：微生物可能是抗GBM病的病因之一1919: GoodpB细胞的线性抗原决定簇合成24条重叠肽段：覆盖3(IV)NC1的234aa起始

18、的线性抗原决定簇：P14（aa129-150） Initiation epitope?Risk epitope?Jia XY, et al. Clin J Am Soc Nephrol 2012 Jun;7(6):926-33B细胞的线性抗原决定簇合成24条重叠肽段：InitiatioP14(22mer)诱发WKY大鼠抗GBM肾炎P14（aa129-150）分子内抗原决定簇扩展诱发自身免疫性T细胞增殖T/B细胞共同抗原决定簇Unpublished dataP14(22mer)诱发WKY大鼠抗GBM肾炎P14（aa1B细胞的关键抗原决定簇与核心氨基酸基序P14氨基酸序列:P14: TDIPPCP

19、HGWISLWKGFSFIMFP14a:TDIPPCPHGWISLP14b: CPHGWISLWKGFSP14c: ISLWKGFSFIMFTP14c逐个氨基酸突变B细胞识别的关键氨基酸基序GFxF Unpublished dataB细胞的关键抗原决定簇与核心氨基酸基序P14氨基酸序列:P1Critical motif on P14 for pathogenicityP14-1 ADIPPCPHGWISLWKGFSFIMFP14-2 TAIPPCPHGWISLWKGFSFIMFP14-3 TDAPPCPHGWISLWKGFSFIMFP14-4 TDIAPCPHGWISLWKGFSFIMFP14

20、-5 TDIPACPHGWISLWKGFSFIMFP14-6 TDIPPAPHGWISLWKGFSFIMFP14-7 TDIPPCAHGWISLWKGFSFIMFP14-8 TDIPPCPAGWISLWKGFSFIMFP14-9 TDIPPCPHAWISLWKGFSFIMFP14-10 TDIPPCPHGAISLWKGFSFIMFP14-11 TDIPPCPHGWASLWKGFSFIMFP14-12 TDIPPCPHGWIALWKGFSFIMFP14-13 TDIPPCPHGWISAWKGFSFIMFP14-14 TDIPPCPHGWISLAKGFSFIMFP14-15 TDIPPCPHGWI

21、SLWAGFSFIMFP14-16 TDIPPCPHGWISLWKAFSFIMFP14-17 TDIPPCPHGWISLWKGASFIMFP14-18 TDIPPCPHGWISLWKGFAFIMFP14-19 TDIPPCPHGWISLWKGFSAIMFP14-20 TDIPPCPHGWISLWKGFSFAMFP14-21 TDIPPCPHGWISLWKGFSFIAFP14-22 TDIPPCPHGWISLWKGFSFIMAUnpublished dataTryptophan138, Isoleucine139, Leucine141, and Tryptophan142P14129-150: TDIPPCPHGWISLWKGFSFIMFCritical motif on P14 for path抗GBM病-病因研究针对致病微生物的研究细菌、病毒等培养（尚无来源）合成抗原分子利用生物信息学预测可能的T/B细胞抗原决定簇确定抗GBM病患者是否感染血清抗致病微生物蛋白抗体动物实验验证其致病性抗GBM病-病因研究针对致病微生物的研究8 patients with MN and anti-GBM diseaseSequential or simultaneousBetter prognosisAnti-3