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通讯作者:

魏继福,E-mail:weijifu@hotmail.com

中图分类号:R699.2

文献标识码:A

文章编号:1007-4368(2022)04-518-04

DOI:10.7655/NYDXBNS20220409

参考文献 1
CHAPMAN J R.What are the key challenges we face in kidney transplantation today?[J].Transplant Res,2013,2(Suppl 1):S1
参考文献 2
GARCIA G G,HARDEN P,CHAPMAN J,et al.The glob⁃ al role of kidney transplantation[J].Nephrol Dial Trans⁃ plant,2013,28(8):e1-e5
参考文献 3
李晓北,王玮,尹航,等.慢性移植肾功能衰竭危险因素的临床分析[J].中华医学杂志,2014,94(26):2022-2024
参考文献 4
CHAPMAN J R.The KDIGO clinical practice guidelines for the care of kidney transplant recipients[J].Transplan⁃tation,2010,89(6):644-645
参考文献 5
ROBERTS D M,JIANG S H,CHADBAN S J.The treat⁃ ment of acute antibody ⁃ mediated rejection in kidney transplant recipients⁃a systematic review[J].Transplanta⁃ tion,2012,94(8):775-783
参考文献 6
王瑜,汤键.血管细胞黏附分子1(VCAM1)的分子生物学[J].北京大学学报(医学版),1994,26(S1):216-219
参考文献 7
KONG D H,KIM Y K,KIM M R,et al.Emerging roles of vascular cell adhesion molecule⁃1(VCAM⁃1)in immuno⁃ logical disorders and cancer[J].Int J Mol Sci,2018,19(4):1057
参考文献 8
LOUPY A,HAAS M,SOLEZ K,et al.The Banff 2015 kid⁃ ney meeting report:current challenges in rejection classi⁃ fication and prospects for adopting molecular pathology [J].Am J Transplant,2017,17(1):28-41
参考文献 9
DENTON M D,DAVIS S F,BAUM M A,et al.The role of the graft endothelium in transplant rejection:evidence that endothelial activation may serve as a clinical marker for the development of chronic rejection[J].Pediatr Transplant,2000,4(4):252-260
参考文献 10
CROSS A R,GLOTZ D,MOONEY N.The role of the en⁃ dothelium during antibody ⁃ mediated rejection:from vic⁃ tim to accomplice[J].Front Immunol,2018,9:106
参考文献 11
NICOSIA M,FAIRCHILD R L,VALUJSKIKH A.Memo⁃ ry T cells in transplantation:old challenges define new di⁃ rections[J].Transplantation,2020,104(10):2024-2034
参考文献 12
ISSA F,SCHIOPU A,WOOD K J.Role of T cells in graft rejection and transplantation tolerance[J].Expert Rev Clin Immunol,2010,6(1):155-169
参考文献 13
LAUTENSCHLAGER I,HÖCKERSTEDT K,TASKINEN E,et al.Expression of adhesion molecules and their li⁃ gands in liver allografts during cytomegalovirus(CMV)infection and acute rejection[J].Transpl Int,1996,9(suppl 1):S213-S215
参考文献 14
HILL P A,MAIN I W,ATKINS R C.ICAM⁃1 and VCAM⁃ 1 in human renal allograft rejection[J].Kidney Int,1995,47(5):1383-1391
参考文献 15
HERSKOWITZ A,MAYNE A E,WILLOUGHBY S B,et al.Patterns of myocardial cell adhesion molecule expres⁃ sion in human endomyocardial biopsies after cardiac transplantation.Induced ICAM ⁃1 and VCAM ⁃1 related to implantation and rejection[J].Am J Pathol,1994,145(5):1082-1094
参考文献 16
HART C,KLATT S,BAROP J,et al.Splenic pooling and loss of VCAM⁃1 causes an engraftment defect in patients with myelofibrosis after allogeneic hematopoietic stem cell transplantation[J].Haematologica,2016,101(11):1407-1416
参考文献 17
KLODA K,DOMANSKI L,PAWLIK A,et al.Effect of the ICAM1 and VCAM1 gene polymorphisms on delayed graft function and acute kidney allograft rejection[J].Ann Transplant,2010,15(4):15-20
目录contents

    摘要

    目的:阐述血管细胞黏附分子1(vascular cell adhesion molecule 1,VCAM1)基因rs2392221单核苷酸多态性(single nucleotide polymorphism,SNP)与肾移植后急性排异(acute rejection,AR)发生的相关性。方法:回顾性分析南京医科大学第一附属医院 200 例肾移植患者,根据肾移植术后是否发生急性排异分为急性排异(acute rejection,AR)组 69 例和非 AR 组 131例。通过二代测序对VCAM1 rs2392221基因型进行检测。采用5个遗传模型分析VCAM1 rs2392221对AR的影响。结合临床和人口统计学数据,评估 VCAM1 rs2392221 基因多态性与肾移植术后急性排异的关联。结果:5 个遗传模型研究显示 VCAM1 rs2392221与肾移植术后急性排异显著相关,共显性模型 CC vs. CT:OR=3.71,95%CI:1.82~7.58;CC vs. TT:OR=5.41, 95%CI:1.14~25.75,P < 0.001;显性模型 OR=3.90,95%CI:1.97~7.72,P < 0.001;隐性模型 OR=3.57,95%CI:0.77~16.54,P = 0.357; 超显性模型OR=3.31,95%CI:1.65~6.65,P =0.002;加性模型 OR=3.04,95%CI:1.70~5.43,P =0.034。结论VCAM1 rs2392221与肾移植术后急性排异的发生显著相关,检测VCAM1 rs2392221可能有助于早期诊断急性排异的发生。

    Abstract

    Objective:Our study aims to investigate the correlations between single nucleotide polymorphism rs2392221 in vascular cell adhesion molecule 1(VCAM1)and the risk of acute rejection(AR)in renal transplant recipients. Methods:A total of 200 Chinese renal transplant recipients who underwent kidney transplantation at our center of the First Affiliated Hospital of Nanjing Medical University,were enrolled and divided into non⁃AR group(n=131)and AR group(n=69). The VCAM1 rs2392221 genotypes were detected by next generation sequencing. Five adjusted inheritance models were utilized to investigate the influence of VCAM1 rs2392221 on AR. Combining clinical and demographic data,the association between VCAM1 rs2392221 gene polymorphisms and AR in renal transplant recipients was evaluated. Results:The SNP rs2392221 on VCAM1 gene exhibited significant correlation with the occurrence of AR in four of the five models as P < 0.001 in codominant model(CC vs. CT:OR=3.71,95%CI:1.82~7.58;CC vs. TT: OR=5.41,95%CI:1.14~25.75),P < 0.001 in dominant model(OR=3.90,95% CI:1.97~7.72),P =0.357 in recessive model(OR=3.57, 95% CI:0.77~16.54),P =0.002 in over⁃dominant model(OR=3.31,95% CI:1.65~6.65),P =0.034 in log⁃additive model(OR=3.04, 95% CI:1.70~5.43). Conclusion:In this study,we observed that SNP rs2392221 was significantly related to the occurrence of AR in Chinese renal transplant recipients,thereby indicating a potential target for the early diagnosis of AR.

  • 肾移植被认为是终末期肾脏病患者最有效的肾脏替代治疗方式之一[1]。与透析相比,肾移植患者的生活质量更高[2]。但一些肾移植相关的并发症,如急性排异、慢性移植物功能障碍、免疫抑制剂相关的肾毒性,增加了慢性肾脏病患者对移植的担忧[3-4]。此外,肾移植后发生严重并发症如急性排异会进一步导致移植物失功,慢性移植物功能障碍风险增加[5]。因此,了解急性排异的病理生理机制对肾移植患者短期及长期预后至关重要。

  • 血管细胞黏附分子1(vascular cell adhesion mol⁃ ecule1,VCAM1)是定位于细胞膜上,属免疫球蛋白超家族的黏附分子,其分子量为110kDa。它特异地与白细胞(除中性粒细胞外)所产生的属Integrin家族的黏附分子VLA⁃4结合,介导细胞黏附和信号转导,在细胞分化、炎症反应、动脉粥样硬化等多种病理过程中发挥作用[6]。较多研究显示,VCAM1与移植排异相关[7]。本研究旨在探讨VCAM1rs2392221基因多态性与肾移植术后急性排异发生之间的关系。

  • 1 对象和方法

  • 1.1 对象

  • 入选2011年2月—2015年12月在南京医科大学第一附属医院肾移植的200例患者为研究对象。纳入标准:①年龄18~60岁;②肾移植术后至少3个月内肌酐稳定[肌酐< 120 μmol/L,3个月内未发生急性排异、肾功能延迟恢复(delayed graft function, DGF)或者机会性感染];③肾移植术后随访6个月以上。排除标准:①慢性病毒感染如乙型肝炎、丙型肝炎、艾滋病患者;②妊娠患者。本研究经南京医科大学第一附属医院伦理委员会批准(2016⁃ SR⁃029),所有患者均签署知情同意书。

  • 1.2 方法

  • 根据Banff 15标准诊断急性排异的患者。根据间质浸润和动脉内膜炎的程度对AR进行评分[8]。随访期间发生急性排异的患者纳入AR组,未发生急性排异的患者纳入非AR组。收集患者的临床资料,包括年龄、性别、身高、急性排异发生的情况、移植DGF的情况以及肾移植患者的免疫用药方案。

  • 1.2.1 基因检测

  • 检测步骤:①收集患者的外周血样本2mL。提取DNA后,利用琼脂糖凝胶电泳定量分析基因组DNA(gDNA)的浓度和纯度,并对基因完整性进行评估;②gDNA被添加到含上游和下游特异性的目标区域的寡核苷酸混合物中。应用非接触式超声波破碎仪(Diagenode,比利时)裂解gDNA。裂解后进行末端修饰,添加接头,PCR扩增;③扩增后按照制造商说明书将DNA加载到Illumina cBot仪器中,再基于人类参考基因组hg19数据使用Genome Analy⁃ sis Tool Kit、Picard软件和dbSNP 132进行分析。

  • 1.2.2 免疫抑制治疗

  • 所有移植受者的免疫诱导方案为巴利昔单抗。免疫维持方案为3种或4种免疫抑制药物:环孢素或他克莫司联合霉酚酸酯和泼尼松,加或不加西罗莫司。免疫抑制药物的剂量根据患者血肌酐水平及血药浓度调整。当患者出现急性排异时,糖皮质激素方案为甲强龙200mg/d,冲击治疗3~5d。

  • 1.3 统计学方法

  • 用SPSS24.0软件进行统计分析。计量资料以均值±标准差(x- ± s)表示。计数资料用率表示。采用Logistic回归分析基因型分布与急性排异的关联性,并计算各模型相关的比值比(odds ratio,OR)及95%可信区间(confident interval,CI)。P< 0.05为差异有统计学意义。

  • 2 结果

  • 2.1 一般资料

  • 研究共纳入200例肾移植患者,男124例,女76例。200例中有69例(男42例,女27例)发生至少1次急性排异。2组患者的一般资料比较,差异无统计学意义(P> 0.05,表1)。

  • 2.2 VCAM1 rs2392221基因多态性与AR的相关性

  • 对VCAM1rs2392221与AR发生之间的关系进行分析发现,VCAM1rs2392221基因多态性与AR的发生显著相关。共显性模型CC vs.CT:OR=3.71, 95%CI:1.82~7.58;CC vs.TT:OR=5.41,95%CI:1.14~25.75,P< 0.001;显性模型OR=3.90,95%CI:1.97~7.72,P< 0.001;隐性模型OR=3.57,95%CI:0.77~16.54,P=0.357;超显性模型OR=3.31,95%CI: 1.65~6.65,P=0.002;加性模型OR=3.04,95%CI: 1.70~5.43,P=0.034(表2)。

  • 3 讨论

  • 细胞黏附分子与白细胞向炎症部位的转运和聚集密切相关,如巨噬细胞和T细胞。近年来研究显示,VCAM1可能与免疫相关疾病的进展显著相关,如移植排异。由于器官移植供者或受者不匹配,所以移植后会发生移植排斥反应。移植排斥反应是由白细胞向炎症部位浸润引起的。淋巴细胞和单核细胞在排斥反应中起核心作用,并最终导致移植物损伤[9-12]。移植排斥反应是受者白细胞和供者内皮细胞之间复杂的相互作用。在过去几十年里,许多关于移植排斥的研究显示VCAM1在移植器官的内皮细胞表达上调,包括肝、肾、肺和心脏。 Lautenschlager等[13] 研究显示,肝移植患者发生急性排异时,VCAM1在血管内皮表达显著增加。Hill等[14] 研究显示在肾移植排斥反应中,VCAM1在肾小管周毛细血管内皮表达上调,且主要表达于小管基底外侧表面。心脏移植患者发生急性排异时心肌内膜活检也显示VCAM1表达增加[15]。此外,Hart等[16] 研究显示VCAM1在造血干细胞移植也起到重要作用。因此,VCAM1的表达可能在移植排斥反应中发挥重要作用,并可能成为移植排斥反应的生物标志物。但目前缺乏VCAM1基因多态性与移植排异相关性的研究。

  • 表1 2组患者的一般资料比较

  • Table1 Comparison of baseline characteristics between AR and non⁃AR subjects

  • 表2 rs2392221基因多态性与急性排异发生相关性分析

  • Table2 Results of multiple inheritance analysis of rs2392221with the occurrence of acute rejection in five models

  • VCAM1rs2392221突变首次发现与肾移植急性排异相关。根据本研究结果,常规开展VCAM1rs2392221基因检测是优化肾移植患者维持免疫治疗方案的直接方法。通过基因分析,提前对潜在肾移植AR患者进行鉴别,可以帮助早期诊断急性排异,及时调整肾移植患者免疫抑制方案,改善肾移植患者预后。当然,本研究也存在较多不足,首先本研究未对VCAM1基因其他已报道过的突变位点进行检测和分析[17],其次本研究未分析肾脏病理与VCAM1rs2392221的相关性。未来需要更大更多的临床研究以及体外功能试验来证实我们的观点。

  • 综上,本研究显示VCAM1rs2392221基因多态性与肾移植患者急性排异的发生显著相关, VCAM1rs2392221的基因检测可能有助于移植排异的早期诊断及治疗。

  • 参考文献

    • [1] CHAPMAN J R.What are the key challenges we face in kidney transplantation today?[J].Transplant Res,2013,2(Suppl 1):S1

    • [2] GARCIA G G,HARDEN P,CHAPMAN J,et al.The glob⁃ al role of kidney transplantation[J].Nephrol Dial Trans⁃ plant,2013,28(8):e1-e5

    • [3] 李晓北,王玮,尹航,等.慢性移植肾功能衰竭危险因素的临床分析[J].中华医学杂志,2014,94(26):2022-2024

    • [4] CHAPMAN J R.The KDIGO clinical practice guidelines for the care of kidney transplant recipients[J].Transplan⁃tation,2010,89(6):644-645

    • [5] ROBERTS D M,JIANG S H,CHADBAN S J.The treat⁃ ment of acute antibody ⁃ mediated rejection in kidney transplant recipients⁃a systematic review[J].Transplanta⁃ tion,2012,94(8):775-783

    • [6] 王瑜,汤键.血管细胞黏附分子1(VCAM1)的分子生物学[J].北京大学学报(医学版),1994,26(S1):216-219

    • [7] KONG D H,KIM Y K,KIM M R,et al.Emerging roles of vascular cell adhesion molecule⁃1(VCAM⁃1)in immuno⁃ logical disorders and cancer[J].Int J Mol Sci,2018,19(4):1057

    • [8] LOUPY A,HAAS M,SOLEZ K,et al.The Banff 2015 kid⁃ ney meeting report:current challenges in rejection classi⁃ fication and prospects for adopting molecular pathology [J].Am J Transplant,2017,17(1):28-41

    • [9] DENTON M D,DAVIS S F,BAUM M A,et al.The role of the graft endothelium in transplant rejection:evidence that endothelial activation may serve as a clinical marker for the development of chronic rejection[J].Pediatr Transplant,2000,4(4):252-260

    • [10] CROSS A R,GLOTZ D,MOONEY N.The role of the en⁃ dothelium during antibody ⁃ mediated rejection:from vic⁃ tim to accomplice[J].Front Immunol,2018,9:106

    • [11] NICOSIA M,FAIRCHILD R L,VALUJSKIKH A.Memo⁃ ry T cells in transplantation:old challenges define new di⁃ rections[J].Transplantation,2020,104(10):2024-2034

    • [12] ISSA F,SCHIOPU A,WOOD K J.Role of T cells in graft rejection and transplantation tolerance[J].Expert Rev Clin Immunol,2010,6(1):155-169

    • [13] LAUTENSCHLAGER I,HÖCKERSTEDT K,TASKINEN E,et al.Expression of adhesion molecules and their li⁃ gands in liver allografts during cytomegalovirus(CMV)infection and acute rejection[J].Transpl Int,1996,9(suppl 1):S213-S215

    • [14] HILL P A,MAIN I W,ATKINS R C.ICAM⁃1 and VCAM⁃ 1 in human renal allograft rejection[J].Kidney Int,1995,47(5):1383-1391

    • [15] HERSKOWITZ A,MAYNE A E,WILLOUGHBY S B,et al.Patterns of myocardial cell adhesion molecule expres⁃ sion in human endomyocardial biopsies after cardiac transplantation.Induced ICAM ⁃1 and VCAM ⁃1 related to implantation and rejection[J].Am J Pathol,1994,145(5):1082-1094

    • [16] HART C,KLATT S,BAROP J,et al.Splenic pooling and loss of VCAM⁃1 causes an engraftment defect in patients with myelofibrosis after allogeneic hematopoietic stem cell transplantation[J].Haematologica,2016,101(11):1407-1416

    • [17] KLODA K,DOMANSKI L,PAWLIK A,et al.Effect of the ICAM1 and VCAM1 gene polymorphisms on delayed graft function and acute kidney allograft rejection[J].Ann Transplant,2010,15(4):15-20

  • 参考文献

    • [1] CHAPMAN J R.What are the key challenges we face in kidney transplantation today?[J].Transplant Res,2013,2(Suppl 1):S1

    • [2] GARCIA G G,HARDEN P,CHAPMAN J,et al.The glob⁃ al role of kidney transplantation[J].Nephrol Dial Trans⁃ plant,2013,28(8):e1-e5

    • [3] 李晓北,王玮,尹航,等.慢性移植肾功能衰竭危险因素的临床分析[J].中华医学杂志,2014,94(26):2022-2024

    • [4] CHAPMAN J R.The KDIGO clinical practice guidelines for the care of kidney transplant recipients[J].Transplan⁃tation,2010,89(6):644-645

    • [5] ROBERTS D M,JIANG S H,CHADBAN S J.The treat⁃ ment of acute antibody ⁃ mediated rejection in kidney transplant recipients⁃a systematic review[J].Transplanta⁃ tion,2012,94(8):775-783

    • [6] 王瑜,汤键.血管细胞黏附分子1(VCAM1)的分子生物学[J].北京大学学报(医学版),1994,26(S1):216-219

    • [7] KONG D H,KIM Y K,KIM M R,et al.Emerging roles of vascular cell adhesion molecule⁃1(VCAM⁃1)in immuno⁃ logical disorders and cancer[J].Int J Mol Sci,2018,19(4):1057

    • [8] LOUPY A,HAAS M,SOLEZ K,et al.The Banff 2015 kid⁃ ney meeting report:current challenges in rejection classi⁃ fication and prospects for adopting molecular pathology [J].Am J Transplant,2017,17(1):28-41

    • [9] DENTON M D,DAVIS S F,BAUM M A,et al.The role of the graft endothelium in transplant rejection:evidence that endothelial activation may serve as a clinical marker for the development of chronic rejection[J].Pediatr Transplant,2000,4(4):252-260

    • [10] CROSS A R,GLOTZ D,MOONEY N.The role of the en⁃ dothelium during antibody ⁃ mediated rejection:from vic⁃ tim to accomplice[J].Front Immunol,2018,9:106

    • [11] NICOSIA M,FAIRCHILD R L,VALUJSKIKH A.Memo⁃ ry T cells in transplantation:old challenges define new di⁃ rections[J].Transplantation,2020,104(10):2024-2034

    • [12] ISSA F,SCHIOPU A,WOOD K J.Role of T cells in graft rejection and transplantation tolerance[J].Expert Rev Clin Immunol,2010,6(1):155-169

    • [13] LAUTENSCHLAGER I,HÖCKERSTEDT K,TASKINEN E,et al.Expression of adhesion molecules and their li⁃ gands in liver allografts during cytomegalovirus(CMV)infection and acute rejection[J].Transpl Int,1996,9(suppl 1):S213-S215

    • [14] HILL P A,MAIN I W,ATKINS R C.ICAM⁃1 and VCAM⁃ 1 in human renal allograft rejection[J].Kidney Int,1995,47(5):1383-1391

    • [15] HERSKOWITZ A,MAYNE A E,WILLOUGHBY S B,et al.Patterns of myocardial cell adhesion molecule expres⁃ sion in human endomyocardial biopsies after cardiac transplantation.Induced ICAM ⁃1 and VCAM ⁃1 related to implantation and rejection[J].Am J Pathol,1994,145(5):1082-1094

    • [16] HART C,KLATT S,BAROP J,et al.Splenic pooling and loss of VCAM⁃1 causes an engraftment defect in patients with myelofibrosis after allogeneic hematopoietic stem cell transplantation[J].Haematologica,2016,101(11):1407-1416

    • [17] KLODA K,DOMANSKI L,PAWLIK A,et al.Effect of the ICAM1 and VCAM1 gene polymorphisms on delayed graft function and acute kidney allograft rejection[J].Ann Transplant,2010,15(4):15-20

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