注射用重组人Ⅱ型肿瘤坏死因子受体-抗体融合蛋白对幼年特发性关节炎患儿外周血关节液软骨寡聚基质蛋白表达的影响

Influence of rhTNFR：FC on expression of cartilage oligomeric matrix protein in synovial fluid and peripheral blood among juvenile idiopathic arthritis

目的 观察注射用重组人Ⅱ型肿瘤坏死因子受体-抗体融合蛋白（rhTNFR：FC）对幼年特发性关节炎（JIA）患儿外周血、关节液软骨寡聚基质蛋白（COMP）表达的影响,探讨COMP在JIA中的临床意义以及rhTNFR：FC治疗JIA时与COMP的关系.方法 ①选取35例JIA患儿（JIA组）,30例外伤性关节炎患儿（外伤组）,30例腹股沟斜疝修补术患儿（正常组）,入院确诊时治疗前抽血待检COMP,JIA组中15例、外伤组中10例患儿治疗前抽关节液待检COMP.②35例JIA组中有15例采用rhTNFR：FC联合DMARDs联合NSAIDs治疗方案（A组）,20例采用DMARDs联合NSAIDs治疗方案（B组）,35例JIA患儿治疗3～6个月达到疾病不活动时抽血待检COMP,A组中有5例患儿治疗后抽关节液待检COMP.同时评估JIA患儿治疗前后关节压痛数、关节肿胀数、晨僵时间、血常规、ESR、CRP等指标.③采用ELISA法检测COMP.计量资料采用t检验或方差分析,计数资料采用x2检验或Fisher确切概率法,变量间关系用Pearson相关分析.结果 ①治疗前血清COMP水平JIA组（0.77±0.29） ng/ml、外伤组（1.00±0.28） ng/ml明显低于正常组（1.33±0.37） ng/ml,差异有统计学意义（F=25.345,P＜0.05）,3组两两比较差异有统计学意义（P均＜0.05）.②治疗前关节液COMP水平JIA组（14.8±1.6） ng/ml与外伤组（15.1±1.0） ng/ml差异无统计学意义（t=0.523,P=0.606）.③治疗前全身型JIA血清COMP水平（0.26±0.03） ng/ml明显低于少关节型JIA （0.87 ±0.17） ng/ml、与附着点炎症相关型关节炎（0.89±0.22） ng/ml及多关节型JIA （0.70±0.35） ng/ml,差异有统计学意义（F=9.244,P＜0.05）.④治疗前JIA组血清COMP水平与白细胞、CRP、ESR呈负相关（r=-0.556、-0.582、-0.684,P均＜0.05）,与关节压痛指数、关节肿胀指数、晨僵、血红蛋白、血小板无相关（r=0.06、-0.206、-0.107、0.15、-0.185,P均＞0.05）.⑤JIA中存在关节破坏的患儿血清COMP水平（0.52±0.22） ng/mlml明显低于无关节破坏的患儿（0.92±0.22） ng/ml,差异有统计学意义（t=5.207,P＜0.05）.⑥治疗后血清COMP水平A组（1.33±0.21） ng/ml、B组（0.96±0.22） ng/ml明显高于治疗前JIA组（0.77±0.29） ng/ml,且A组高于B组,差异有统计学意义（F=24.681,P均＜0.05）.⑦治疗后关节液COMP水平（18.4±1.1） ng/ml（5例）高于治疗前（14.8±1.6） ng/ml（15例）,差异有统计学意义（t=4.565,P＜0.05）.结论 血清、关节液COMP水平在JIA患儿治疗前下降,治疗后上升,联合rhTNFR：FC治疗后上升更明显,血清COMP与炎症指标CRP、ESR、白细胞呈负相关,在全身型JIA、关节破坏JIA患儿中明显下降,推测COMP可能参与JIA的发病过程,可能成为JIA疾病活动、关节破坏、生长抑制的预测指标,rhTNFR：FC治疗JIA可促进COMP的恢复。

Objective To explore the effect of recombinant human tumor necrosis factor-α receptor Ⅱ：IgG Fc fusion protein injection （rhTNFR：FC） on the expression of cartilage oligomeric matrix protein （COMP） in the synovial fluid and peripheral blood of juvenile idiopathic arthritis （JIA）; and to explore the clinical significance of COMP for JIA and the relationship between rhTNFR：FC and COMP in JIA.Methods Thirty-five patients with JIA （JIA group）,30 patients with traumatic arthritis （trauma group） and 30 patients with indirect inguinal hernia hernioplasty （normal group） were included.Peripheral blood from all enrolled patients and synovial fluid from 15 JIA and 10 trauma arthritis were obtained for COMP detection before the treatment.Fifteen JIA （group A） patients were treated with combined rhTNFR：FC,diseasemodifying antirheumatic drugs （DMARDs） and non-steroid anti-inflammatory drugs （NSAIDs）,20 JIA （group B） were treated with combined DMARDs and NSAIDs.After three to six months＇ treatment and when the disease were in remission,peripheral blood from group A and B were drawn for COMP detection.In group A,the synovial fluid from 5 patients were obtained for COMP detection after treatment.At the same time,such as tender joint count （TJC）,swollen joint count （SJC）,time for morning stiffness,blood routine,erythrocyte sedimentation rate （ESR）,and C-reactive protein （CRP） and other parameters before and after treatment were measured.The level of COMP was tested by double antibody sandwich enzyme-linked immunosorbent assay.The measurement data were tested for variance and independent sample t-test; and the enumeration data were tested by chi-squared or Fisher＇s exact test.Pearson＇s correlation analysis was adopted to analyze the association among the variables.Results ① The blood COMP level before treatment was （0.77±0.29） ng/ml in the JIA group,（1.00±0.28） ng/ml in the traumatic arthritis group,and （1.33±0.37） ng/ml in the normal control group.The level in the former two groups was obviously lower than that in the normal control group.The variation was statistically significant （F=25.345,P＜0.05）.The comparison between any two groups was statistically significant （P＜0.05）.② The COMP level in the synovial fluid before treatment were （14.8±1.6） ng/ml in the JIA group,（15.1±1.0） ng/ml in the traumatic arthritis group.The variation was not stati-stically significant （t=0.523,P=0.606）.③ The serum COMP level of the systemic JIA group was obviously lower than that of the oligoarticular JIA patients,and patients with enthesitis-related arthritis and polyarticular JIA （0.26± 0.03 vs.0.87±0.17,0.89±0.22 and 0.70±0.35 ng/ml,respectively; F=9.244,P＜0.05）.④ The serum COMP level of JIA at the acute phase was negatively correlated with white blood cells count （WBC）,CRP and ESR （r=-0.556,-0.582 and-0.684,respectively; P all＜0.05）.By contrast,no correlation was detected between the serum COMP level and joint tenderness index,joint swelling index,morning stiffness duration,hemoglobin level and platelet count（r=0.06,-0.206,-0.107,0.15 and-0.185,respectively; P all ＞0.05）.⑤ The serum COMP level was obviously lower in the JIA with joint destruction than that without joint destruction （0.52±0.22 vs.0.92±0.22 ng/ml; t=5.207,P＜0.05）.⑥After treatment,the blood COMP level in group A was （1.33±0.21） ng/ml and （0.96±0.22） ng/ml in group B,which was obviously higher than that in the JIA group before treatment （0.77±0.29） ng/ml.In addition,the level in group A was higher than that in group B.The variation was statistically significant （F=24.681,P＜0.05）.⑦ After treatment,the COMP level in the synovial fluid （18.4± 1.1） ng/ml （n=5） was higher than that before the treatment was （14.8± 1.6） ng/ml （n =15）.The variation was of statistical significant （t=4.565,P＜0.05）.Conclusion The COMP level in blood and synovial fluid declines before treatment and increases after treatment.The increase is more obvious after combined with rhTNFR：FC treatment.The serum COMP level is remarkably decreased in JIA at the acute phase,systemic JIA,and the JIA with destruction of joint,and showes a negative correlation with WBC,CRP and ESR.Serum COMP may be a useful marker of active disease,destruction of joint and growth inhibition for patients with JIA.rhTNFR：FC treatment for JIA can facilitate the recovery of COMP.