抗肾小球基底膜(GBM)病

抗肾小球基底膜(GBM)病*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）*GoodpasureEM.AmJMedSci1919;158:863-870CuiZ,ZhaoMH.NatRevNephrol.2011Dec7:697-706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：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CuiZ,ZhaoMH.NatRevNephrol.2011Dec7:697-706抗GBM病研究现状*HudsonGB.VanderbiltUniversityGBMmoleculararchitectureofconformationalepitopesPuseyCD.HammersmithImperialCollegeLondonPEinanti-GBMdiseaseWKYratmodelGeneticsofEAGmodelsSegelmarkM&WieslanderJLundUniversityRecombinantantigensDetectionofanti-GBMdiseaseZhaoMH&CuiZPekingUniversityHumananti-GBMdiseaseLinearepitopesMolecularmimicryKitchingAR.MonashUniversity.MHCandTcellactivationAnimalmodelsLouYH.UniversityofTexasTcellepitopeAnimalmodel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SausJ,etal.JBiolChem1988;15;263:13374-80SalantDJ.NEnglJMed2010;363;4:381-391*抗GBM病的科学问题病因 表 关于同志近三年现实表现材料材料类招标技术评分表图表与交易pdf视力表打印pdf用图表说话 pdf 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？23/M间断咯血4个月，加重1个月HGB:71g/L;PO258mmHg;Scr94.0μmol/l尿常规:protein(+),RBC5-8/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：Pred1mg/kg/dx8w,无PE和CTX随访7年肾功能正常CuiZ,etal.KidneyInt2007;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？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？CuiZ,etal.KidneyInt2006:69:894-9CuiZ,etal.KidneyInt2010;78:590-7Naturalanti-GBMab*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Anti-GBM(+)正常肾功能正常人病人A病人CIntra-moleculeEpitopespreading3,41、2、3、4和5SubclassswitchingIgG2、IgG4IgG1、IgG2、IgG3和IgG4治疗个体化T细胞调控3Ea、Eb3内其他位点*Anti-GBM(+)轻度肾受累病人BCuiZ,etal.KidneyInt2006;69:894-9.YangR,etal.JAmSocNephrol2007;18(4):1338-43.CuiZ,etal.KidneyInt2007;72(11):1403-8.ZhaoJ&CuiZ,etal.KidneyInt.2009;76:1108-15.CuiZ,etal.KidneyInt2010;78(6):590-7.ChenJL&HuSY,etal.ClinJAmSocNephrol.2013;8(1):51-8.Inter-moleculeEpitopespreadingNATUREREVIEWS|NEPHROLOGYCuiZ,ZhaoMH.NatRevNephrol.2011Dec;7:697-706.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病合并MN个例报道MN→GBMdamage：释放α3→抗GBM病抗GBM病→足细胞损伤：表达M-PLA2R→MN*8patientswithMNandanti-GBMdiseaseSequentialorsimultaneousBetterprognosisAnti-α3(+):narrowantigenspectrumAnti-PLA2R(-)JiaXY,etal.KidneyInt2014Apr;85(4):945-52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病的免疫学发病机制?LineartoConformational涉及感染、抗原递呈、抗原决定簇扩展、分子模拟*Background(HLA)HLAgeneLocation:CHR6p21.3ClassicalHLAgeneMHCclassIImolecular:Distribution:DCs、Bcells、MøStructure:hetero-dimerrecognizedbyCD4+TcellAgprocessed、presentationMHC&disease:MS、RA、IDDM、SLEetal.(Rees,KidInt,1999)DominantlyprotectiveallelesDR1andDR7NogenedosageeffectMHCIIdominantprotectionHLA-DRB1*01:01generates3136-146specificregulatoryTcells.HLA-DRB1*15:01generates3136-146specificeffectorTcellprecursors.InHLA-DRB1*15:01x01:01mice,3136-146specificeffectorTcellprecursorsaredominantlysuppressedby3136-146specificregulatoryTcellsReesetal,KidneyInt1999Ooietal,JAmSocNephrol2013DRB1*1501allele：p=1.597×10−7DRB1*0404allele：p=0.037PatientswithDRB1*1501or*0404hadmorecrescentformation.(p=0.021).YangR.etal.ClinImmunol2009;133:245-250*AssociationofHLAalleles(4digits,P<3.55E-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-4*Determinethesignificant variationmarkerofgenotypeCase:138vs.Control:599rs41541412:theonlysignificantSNP,belongstoDQA1*0502nonsensemutation,changethe82thAAofDQαpolypeptide.CHRSNPCaseControlCHISQP-valOR632609249.C0.02550.00083524.626.99E-730.69632609249.G0.02550.00083524.626.99E-730.69AssociationofanovelHLASNP(P<1.9E-4)Unpublisheddata*Extendedhaplotypecase_freControl_freHaplo.scoreP-valDRB1*1501-DQB1*06020.290.0958.8389.7×10-19DRB1*1501-DRB1*06010.0270.00784.1183.8×10-5DRB1*0901-DQB1*03030.0220.1-4.3121.6×10-5DRB1*1501-DQA1*0102-DQB1*06020.190.094.621.0×10-6DRB1*0901-DQA1*0302-DQB1*03030.0110.092-4.487.3×10-6DRB1*1501-DQA1*0102-DQB1*0602-DPB1*02010.0840.0343.50.00042DRB1*0901-DQA1*0302-DQB1*0303-DPB1*05010.00410.056-3.50.00042ExtendedhaplotypesamongHLA-DRB1,DQA1,DQB1,DPB1inanti-GBMdiseaseUnpublisheddataAllele-1Allele-2D'r2LODscoreDRB1*1501DQB1*06020.5620.30551.22DRB1*1501DRB1*090110.03910.41DRB1*1501DQB1*03030.8170.0244.44DRB1*1501DQA1*05020.2430.0011.03DQB1*0602DRB1*09010.6850.0182.81DQB1*0602DQB1*030310.0358.55DQB1*0602DQA1*05020.460.0050.82DQB1*0303DRB1*09010.6410.38556.05DQB1*0303DQA1*050210.0010.47DQA1*0502DRB1*09010.14800*LOD>3:Confirmedlinkage.LOD<-2:Nolinkage.LOD=0:thepossibilityisequalLinkageanalysisamongthesignificantallelesUnpublisheddata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病的科学问题病因易感性诱发因素病因：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？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?GoodpasureEM.AmJMedSci1919;158:863-870*分子模拟B细胞表位T细胞表位*B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起始的线性抗原决定簇：P14（aa129-150）Initiationepitope?Riskepitope?JiaXY,etal.ClinJAmSocNephrol2012Jun;7(6):926-33P14(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*UnpublisheddataB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:TDIPPCPHGWISLWKGFSFIMFP14a: TDIPPCPHGWISL                         P14b: CPHGWISLWKGFSP14c:ISLWKGFSFIMFT*P14c逐个氨基酸突变B细胞识别的关键氨基酸基序GFxFUnpublisheddata*CriticalmotifonP14forpathogenicityP14-1ADIPPCPHGWISLWKGFSFIMFP14-2TAIPPCPHGWISLWKGFSFIMFP14-3TDAPPCPHGWISLWKGFSFIMFP14-4TDIAPCPHGWISLWKGFSFIMFP14-5TDIPACPHGWISLWKGFSFIMFP14-6TDIPPAPHGWISLWKGFSFIMFP14-7TDIPPCAHGWISLWKGFSFIMFP14-8TDIPPCPAGWISLWKGFSFIMFP14-9TDIPPCPHAWISLWKGFSFIMFP14-10TDIPPCPHGAISLWKGFSFIMFP14-11TDIPPCPHGWASLWKGFSFIMFP14-12TDIPPCPHGWIALWKGFSFIMFP14-13TDIPPCPHGWISAWKGFSFIMFP14-14TDIPPCPHGWISLAKGFSFIMFP14-15TDIPPCPHGWISLWAGFSFIMFP14-16TDIPPCPHGWISLWKAFSFIMFP14-17TDIPPCPHGWISLWKGASFIMFP14-18TDIPPCPHGWISLWKGFAFIMFP14-19TDIPPCPHGWISLWKGFSAIMFP14-20TDIPPCPHGWISLWKGFSFAMFP14-21TDIPPCPHGWISLWKGFSFIAFP14-22TDIPPCPHGWISLWKGFSFIMAUnpublisheddataTryptophan138,Isoleucine139,Leucine141,andTryptophan142P14129-150:TDIPPCPHGWISLWKGFSFIMF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*8patientswithMNandanti-GBMdiseaseSequentialorsimultaneousBetterprognosisAnti-α3(+):narrowantigenspectrumAnti-PLA2R(-)原因？JiaXY,etal.KidneyInt2014Apr;85(4):945-52人α3(IV)NC1诱发了小鼠膜性肾病DBA/1mice(vs.WKYrat)rh-a3(IV)NC1NephroticSyndromeEM：MN*ZhangJJ,etal.JImmunol.2012Apr1;188(7):3268-77MembranousnephropathyinducedbyP13,P14,P15onDBA/1mice*UnpublisheddataMicrobial?HLA-DRB1*1501LikeH-2?MHC?Anti-GBMdiseaseMNPodocyteprotein?Podocyteα3？抗原递呈---MHC-II:DBA1micevs.WKYratHuman？靶抗原小鼠α3？足细胞抗原？病因---关键氨基酸与分子模拟？Humanα3Intra-moleculeepitopespreadingInter-moleculeepitopespreadingRatα3小结抗GBM病并非罕见,仍为肾科医生的挑战自身抗体免疫学特性的变化与疾病进展密切相关抗GBM病的病因有待明确和证实*