纖維母細胞生長因子21與疾病之相關性探討: 從粒腺體到糖尿病腎病變

The Investigation of Association between Fibroblast Growth Factor-21 and Related Disease: From Mitochondria to Diabetic Nephropathy

蘇矢立(Shih-Li Su)

指導教授 ： 黃建寜 ； 劉青山

中山醫學大學/醫學院/醫學研究所/博士(2014年)

https://doi.org/10.6834/CSMU.2014.00100

摘要

背景及目的: 纖維母細胞生長因子在許多的疾病所扮演的角色逐漸被大家所注意，過去我們的實驗室發現纖維母細胞生長因子21可協助臨床醫師鑑別是否為粒腺體異常所引發的步態不良疾病。在那同時纖維母細胞生長因子21濃度與患者的高血糖有所相關連。纖維母細胞生長因子是一種調控生物體能量包括葡萄糖及脂類代謝的胜肽，在動物慢性炎性反應實驗中會增加反應，在高血壓的人群中也可看到濃度的倍增，似乎是一個較全面性的生物指標，有利於臨床的篩選及追蹤。腎絲球過濾率與尿蛋白的測定己被廣泛的運用在糖尿病腎病變的早期篩檢，而糖尿病造成的腎絲球病變是造成臺灣成人洗腎的最主要原因。而高血糖、高血壓、年齡較大、病程越久、抽菸、高血脂及男性性別是影響腎絲球功能的危險因子，往往需要監測許多的指標如測血糖、血壓、血脂、腎功能及發炎標記，才儘可能做到滴水不露。過去雖有學者發現纖維母細胞生長因子對糖尿病患者的蛋白尿會有相關聯性，但在不同慢性腎絲球過濾率的纖維母細胞生長因子濃度變化，並不太多見。目前尚未有將腎絲球過濾率與尿蛋白二者合併，來探查纖維母細胞生長因子對糖尿病腎病變的過程中所參與的影響，本實驗的目的就以此出發。
方法: 202位糖尿病受試者，無臨床心血管病史及症狀、無伴隨癌症、無免疫不全者及半年內無急性高血糖併發症如高血糖高滲透壓症、酮酸中毒及低血糖者、無懷孕、不吸煙及酗酒者。在簽署彰化基督教人體試驗委員通過的受試者同意書後，進入本研究。受試者需接受基本身高、體重、腰圍、臀圍及血壓的測量，而在禁食8－10小時後空腹完成血中生化抽血，並需將早上晨起的第一次尿液收集10毫升送檢。生化驗血包含肝、腎功能、血脂肪、葡萄糖、糖化血紅素、胰島素、血管黏附因子如E--選擇素、血管细胞黏附分子、 細胞內黏附分子等，血管內皮生長因子、 基質金屬蛋白酶9以及纖維母細胞生長因子等。依尿中白蛋白與肌酸酐的比值分成正常、微蛋白及巨蛋白尿三組，以ANOVA的方式，檢定三組之間的差異性。依腎絲球過濾率超過 60 ml /min/1.73 m2與否分成無慢性腎病和有慢性腎病二組，運用 t檢定比較二組的差異。更將有無蛋白尿及有無慢性腎病細分成四組，利用ANOVA的方式，檢定四組之間的差距。以Pearson 相關檢定，用二元回歸來確認相關之間的影響。以p 值小於0.05做判斷是否達到統計顯著水準。
結果: 在正常、微蛋白及巨蛋白尿三組的分析中，血管细胞黏附分子及纖維母細胞生長因子會隨著分期的改變而逐漸增加，纖維母細胞生長因子與尿中白蛋白與肌酸酐的比值呈正相關，相關係數0.144 (p =0.03)；血管细胞黏附分子與尿中白蛋白與肌酸酐的比值呈正相關，相關係數0.366 (p <0.01)。二元回歸血管细胞黏附分子仍有Beta值為+0.515。於有無慢性腎病的比較中，腎絲球過濾率與年齡有負相關系數為-0.200 (p =0.02)，與身體質量指數有負相關系數為-0.232 (p =0.01)，與尿素氮有負相關系數為-0.447 (p <0.01)，與肌酸酐有負相關系數為-0.369 (p <0.01)，與細胞內黏附分子有負相關系數為-0.275 (p <0.01)，與血管细胞黏附分子有負相關係數是-0.391 (p <0.01)，與纖維母細胞生長因子21有負相關係數是-0.382 (p <0.01)。以二元回歸模型後有細胞內黏附分子、血管细胞黏附分子、纖維母細胞生長因子、尿素氮及酸酐達到統計差異。尿蛋白加上腎絲球過濾率低於 60 ml /min/1.73 m2易有腎功能變差的情況，且血管细胞黏附分子、 細胞內黏附分子及纖維母細胞生長因子皆會明顯高於其他組別，而在事後檢定中腎絲球過濾率低於 60 ml /min/1.73 m2是一個重要的分界點。在此之前纖維母細胞生長因子與尿中白蛋白與肌酸酐的比是較強的相關，在此之後纖維母細胞生長因子與血管细胞黏附分子的相關就較明顯。
結論: 纖維母細胞生長因子和尿中白蛋白與肌酸酐比值的相關強度隨者慢性腎病的發展而減弱，而纖維母細胞生長因子與血管细胞黏附分子的相關性則因進入慢性腎病而增強。代表著纖維母細胞生長因子在糖尿病腎病變的發展中全程皆有其影響，未到慢性腎病前是與代謝的因素影響腎臟，而到了慢性腎病後是借發炎變化影響腎功能，可做為臨床的指標並可做為臨床新的治療目標。

關鍵字

纖維母細胞生長因子21 ； 粒腺體 ； 糖尿病腎病變

並列摘要

Background and purpose: Fibroblast growth factors play their roles in different diseases became noticed by many scholars gradually. In our previous studies found that fibroblast growth factor 21 can help clinicians to identify whether mitochondrial induced ataxia or not. At that same time, the high concentrations of fibroblast growth factor 21 in mitochondrial ataxia are associated with hyperglycemia. Fibroblast growth factor 21 (FGF21) is a novel peptide which participate the regulation of biological energy such as glucose and lipid metabolism. It will over-express in animal chronic inflammatory reaction experiments and doubling the concentration in the hypertensive population. FGF21 seems a suitable biomarker in clinical screening and tracking. Estimated glomerular filtration rate (eGFR) and measurable albuminuria has been widely used for screening and detection diabetic nephropathy in the early stage. Diabetes associated with nephropathies has become the major causes of adult dialysis in Taiwan and other developing countries. The risk factors of processing nephropathy include higher blood sugar, hypertension, older aging, diabetes duration, smoking, high lipid profiles and male gender. Therefore, clinical physics need to monitor many indicators for comprehensive observation. The aim of this study is try to find the association among the estimated glomerular filtration rate, albuminuria and FGF21,and for the more, to illustrate the role of FGF21 in the diabetes nephropathy.
Materials and Methods: Two hundred and two diabetic subjects without clinical cardiovascular history and symptoms were enrolled into this study. All participants do not have acute hyperglycemic complications such as hyperosmolar syndrome, ketoacidosis and hypoglycemia in recent 6 months. Subjects with cancer, autoimmune disease, pregnancy, smoking and alcoholism were excluded. All are included after the signing the inform consent which is proved by the committee of institutional review board in Changhua Christian Hospital. They will be measured about personal basic height, weight, waist circumference, hip circumference and blood pressure. Blood sampling should be performed after 8 to 10 hours overnight fasting, for the check of kidney, liver function, lipid profiles, glucose, insulin, hemoglobin A1c, e-selectin, intercellular adhesion molecule (ICAM), vascular cell adhesion molecule (VCAM), vascular endothelial growth factor (VEGF), matrix metalloproteinase-9 (MMP-9) and FGF21. The morning awaking first voiding urine was also collected about 10 ml. According to the urinary albumin to creatinine ratio (A/C ratio), subjects were divided into three groups, normal, microalbuminuria and macroalbuminuria. An ANOVA test was done to find the differences between the three groups. Chronic kidney disease (CKD) was defined using the cut point of eGFR 60 ml /min/1.73 m2 . . Despite the presence of albuminuria , we subdivided CKD into four groups and used ANOVA to detect the variances among the groups. Perform Pearson correlation and bivariate linear regression were used to confirm the correlation between the impacts. p-value less than 0.05 are defined as statistical significance standard.
Results: The concentration of VCAM and FGF21 are increasing gradually in various normal, microalbuminuria and macroalbuminuria stages. FGF21 and A/C ratio showed a positive correlation and the correlation coefficient was 0.144 (p = 0.03). The correlation between the VCAM and A/C ratio has also been positively and the correlation coefficient is 0.366 (p <0.01). After bivariate linear regression test, VCAM still revealed a significant factor as a beta value was +0.515. In comparison of the presence or absence of CKD, Glomerular filtration rate (eGFR) and age were a negative correlation coefficient of -0.200 (p = 0.02), a negative correlation coefficient of -0.232 (p = 0.01) with body mass index, and blood urea nitrogen negative correlation coefficient of -0.447 (p <0.01). eGFR and creatinine were negative correlation coefficient of -0.369 (p <0.01). ICAM and eFGR were negative correlation coefficient of -0.275 (p <0.01), and CAM negative correlation coefficient is -0.391, negative correlation coefficient of -0.382 (p <0.01) (p <0.01) with FGF21. ICAM, VCAM, FGF21, blood urea nitrogen and creatinine showed statistical difference. Albuminuria combined with glomerular filtration rate which less than 60 ml / min/1.73 m2 tend to have a deterioration of renal function. Therefore, VCAM, ICAM and FGF21 are significantly higher than other groups. Glomerular filtration rate less than 60 ml / min/1.73 m2 are a critical cut-off point in post-hoc analysis. eGFR above this point, FGF21 and A/C ratio illustrated a strong correlation. eGFR belw, FGF21 and VCAM demonstrated more obvious.
Conclusion: The association between FGF21 and A/C ratio became non-significant after diabetes nephropathy developed into the stage CKD, While the association among FGF21 and VCAM will be enhanced after established CKD. FGF21 have the full impact in the development of diabetic nephropathy. Metabolic disorders made FGF21 compensated over express, leading to affect kidney in preCKD status. FGF21 participating the reaction of inflammation might be interfere the kidney in CKD stage. FGF21 could be used as an indicator of clinical diabetes nephropathy and a potential new therapeutic target to resolve previous problems and rescue deteriorated renal function.

並列關鍵字

Fibroblast Growth Factor-21 ； Mitochondria ； Diabetic Nephropathy

參考文獻

1. Greenland KJ, Zajac JD. Kennedy's disease: pathogenesis and clinical approaches. Intern Med J. 2004;34(5):279-86.

2. Su S, Jou S, Cheng W, Lin T, Li J, Huang C, Lee Y, Soong B, Liu C. Mitochondrial DNA damage in spinal and bulbar muscular atrophy patients and carriers. Clin Chim Acta. 2010;411(9-10):626-30.

3. Su SL, Wang WF, Wu SL, Wu HM, Chang JC, Huang CS, Cheng WL, Soong BW, Lee YC, Li JY, Kuo SJ, Chen M, Huang CN, Liu CS. FGF21 in ataxia patients with spinocerebellar atrophy and mitochondrial disease. Clin Chim Acta. 2012 24;414:225-7.

4. Wen CP, Cheng TY, Tsai MK, Chang YC, Chan HT, Tsai SP, Chiang PH, Hsu CC, Sung PK, Hsu YH, Wen SF. All-cause mortality attributable to chronic kidney disease: a prospective cohort study based on 462 293 adults in Taiwan. Lancet. 2008 28;371(9631):2173-82.

5. Dronavalli S, Duka I, Bakris GL. The pathogenesis of diabetic nephropathy. Nat Clin Pract Endocrinol Metab. 2008;4(8):444-52.