雷公藤多甙联合厄贝沙坦对糖尿病肾病患者尿足细胞排泄影响及机制探讨

The effects and mechanism of tripterygium wilfordii Hook F combination with irbesartan on urinary podocyte excretion in diabetic nephropathy patients

目的观察雷公藤多甙（TwHF）联合厄贝沙坦对糖尿病肾病（DKD）患者尿足细胞的影响，探讨TwHF对DKD患者肾脏保护作用的机制。方法前瞻性入选45例2型糖尿病肾病患者，分为3组，TwHF治疗组（DT，15例）、厄贝沙坦治疗组（DI，15例）及联合治疗组（DTI，15例）。经6周洗脱期后分别给予TwHF（1～2mg·kg^-1～·d^-1）、厄贝沙坦（150～300mg／d）和TwHF联合厄贝沙坦（厄贝沙坦150～300mg／d加TwHF1～2mg·kg^-1～·d^-1）干预12周。15例健康志愿者作为正常对照。采用间接免疫荧光法检测单克隆抗体podocalyxin标记的尿足细胞。双抗体夹心酶联免疫吸附法测定尿结缔组织生长因子（CTGF）、骨桥蛋白（OPN）和转化生长因子β1（TGFβ1）。结果2型糖尿病肾病患者尿脱落足细胞较对照组明显增多（P〈0．01），DKD患者尿中脱落的足细胞检出率为86．6％。尿足细胞阳性DKD患者尿CTGF、OPN及TGFp，表达明显高于阴性尿足细胞者（P〈0．05或0．01）。相关分析表明尿蛋白量与尿足细胞的排泄计数明显相关（r=0．79，P〈0．01）；尿足细胞的排泄计数与尿CTGF、OPN及TGFB。表达水平明显相关（r=0．56、0．41、0．44，P值均〈0．01）。应用TwHF、厄贝沙坦及两者联合干预12周后，尿蛋白及尿足细胞排泄较治疗前均明显减少（P值均〈0．叭）。各治疗组尿CTGF、OPN、TGFB，表达较治疗前均明显降低（P值均〈0．叭），且以联合组变化最明显（P〈0．05）。结论尿脱落足细胞可能是预测DKD进展的有效因子。TwHF对DKD患者尿足细胞有重要的保护作用，其机制可能与抑制CTGF、OPN及TGFB．β1表达有关，TwHF联合厄贝沙坦对DKD患者足细胞保护具有协同作用。

Objective To investigate the effects of the combination of tripterygium wilfordii Hook F （TwHF） and irbesartan on urinary podocyte in diabetic kidney disease （DKD） patients, and to discuss the mechanism of protective effect of TwHF on DKD. Methods A total of 45 type 2 diabetic kidney disease patients were enrolled into this prospective study, and were randomly divided into 3 groups： TwHF treatment group （DT, n = 15）, irbesartan treatment group （DI, n = 15 ）, and TwHF combined with irbesartan treatment group （DTI, n = 15）. After 6 weeks washout, the 3 groups were given TwHF （1-2 mg·kg^-1·d^-1）, irbesartan （150-300 rag/d）, and TwHF （1-2 mg ·kg^-1·d^-1） combined with irbesartan （150-300 mg/d） for 12 weeks respectively. Fifteen healthy volunteers served as controls. Urinary podocytes were identified and quantitated by immunofluoreseence staining of urinary sediments labeled by monoclonal antibody podoealyxin. In addition, we studied urinary connective tissue growth factor （CTGF）, osteopontin （OPN） and transforming growth factor β1 （TGFβ1） concentrations in DKD patients by enzyme-linked immunosorbent assay. Results Urinary detached podocytes were obviously higher in the urine of DKD patients than in healthy controls （P 〈0. 01）. Podocyte detection rate was 86. 6% in the urine of DKD patients. The protein expressions of CTGF, OPN and TGF[31 in patients with urinary podocyte were significantly increased than those without urinary podocyte （ P 〈 0. 05 or 0. 01 ）. Correlation analysis showed that there was positive correlation between urinary protein excretion and urinary podocytes （ r = 0.79, P 〈 0. 01 ） and there were positive correlations between the number of urinary podocytes and urinary protein expressions of CTGF, OPN and TGFI31 （ r = 0. 56, 0. 41, 0. 44, respectively, all P values 〈 0. 01 ）. Urinary albumin excretion and urinary podocytes were significantly decreased in all treatment groups （ P 〈 0. 01 ）, simultaneously, urinary concentrations of CTGF, OPN and TGFβ1 were reduced in all groups at week 12 after intervention of TwHF, irbesartan and TwHF combined with irbesartan（ P 〈 0. 01 ）, and these changes were more distinguished in combined treatment group （ P 〈 0.05 ）. Conclusion Urinary podocyte in the urine may be suggested to be an early effective marker of disease activity in DKD. TwHF may be effective to prevent podocyte injury in DKD, which may be mediated, at least partly, by down-regulating the expression of CTGF, OPN and TGF[3,. There is a synergistic protective effect of TwHF combined with irbesartan on podocyte injury in DKD patients.