【作者】 张细凤；

【导师】 李兴福；

【作者基本信息】 山东大学 ， 内科学（专业学位）， 2014， 博士

【摘要】 背景系统性红斑狼疮(systemic lupus erythematosus, SLE)是一种自身免疫性疾病。该病是以产生多种自身抗体,并由免疫反应介导炎症为特征的累及多器官、多系统的弥漫性结缔组织病,病情轻重不一。近20年来,环磷酰胺(CTX)、糖皮质激素冲击疗法作为重型SLE诱导缓解的常用疗法。狼疮危象常常需要CTX、大剂量甲基泼尼松龙或加用大剂量免疫球蛋白冲击治疗。虽然近年来SLE的治疗方面有许多新进展,但国内外仍以糖皮质激素加免疫抑制剂为主。它们常能有效控制疾病活动、改善病情,有效提高了SLE患者的存活率。但是大剂量免疫抑制剂和糖皮质激素的副作用及并发症也不容忽视。许多临床研究表明,大剂量CTX、甲基泼尼松龙冲击治疗后出现诸如带状疱疹、肺炎、泌尿系感染及脑炎等感染,可见于20%以上的患者。特别是经CTX或甲基泼尼松龙冲击治疗后的患者免疫力低下,并发感染的几率大大增加,已成为SLE患者死亡的主要原因之一。近年来,中医中药在SLE治疗中的作用逐渐引起人们的重视。中医古代文献中虽没有以系统性红斑狼疮为病名的论述,但对其相似或相关论述甚广,历经数千年之积淀,对其论述涉及本病诸多方面。根据其临床症状表现,不少中医学者将它归属于“蝴蝶斑”、“阴阳毒”、“日晒疮”等范畴。目前国内中医学家对此病证认识颇多,大都认为该病的基础是先天禀赋不足。所以补其不足在系统性红斑狼疮中的研究中占重要地位。代表药物如六味地黄丸,此外百令胶囊、白芍总苷等也被常用于SLE的辅助治疗。六味地黄丸是阴中求阳的代表方,具有滋阴补肾的作用。方中由熟地、丹皮、泽泻、山茱萸、山药、茯苓六味药组成。方中用熟地滋肾填精为主,辅以山茱萸养肝肾而涩精,山药补脾肾而固精又配茯苓淡渗脾湿以助山药益脾,茯苓渗水利湿,使浊水下泻,排出外体,泽泻清泄肾火,并防熟地之滋腻,丹皮清泄肝火,凉血散瘀,除骨蒸之热,并制山茱萸之湿。此方历经数百年医家运用其疗效确切,组方严谨合理,成为滋补肾阴的代表方。现代药理研究证实：六味地黄汤能提高模型动物的白细胞介素(IL)-2活性,IL-2具有促进并维持T淋巴细胞在体内外的生长,参与B淋巴细胞抗体产生,本方还能增强红细胞的免疫功能,方中熟地黄有兴奋或调节肾上腺皮质轴功能,拮抗外源性激素对垂体-肾上腺皮质的抑制作用,延缓肝脏对皮质激素的分解,使血中皮质激素升高。六味地黄方不是单纯的免疫促进剂或免疫抑制剂,而是通过调节机体免疫平衡而发挥作用。百令胶囊主要成分为人工虫草菌丝体干粉,与天然虫草效果基本一致,具有补肺肾,益精气的功效。现代药理研究显示百令胶囊具有有抗氧化,提高机体细胞免疫力,升高机体白细胞,调节血脂,抗炎等作用,能减轻长期应用糖皮质激素引起的蛋白质分解增加、提高抗感染能力；且对机体免疫系统具有双向调节的功能,既可减轻免疫抑制药的毒副作用,又协同其他免疫抑制药发挥作用。综上百令胶囊具有一定的抗炎及调节免疫作用而不会引起激素样副作用。百令胶囊和六味地黄丸联合应用对于减少因免疫制剂和激素治疗SLE所致的副作用的研究报道较少,尤其是对SLE并发感染的干预作用研究更少。在过去几年的临床实践中,我们尝试用六味地黄丸联合百令胶囊辅助治疗SLE患者,结果显示,可以有效减低SLE患者感染的几率并能降低感染程度；从而提高临床疗效,降低病死率。为此,特做此相关研究。目的1.观察系统性红斑狼疮(SLE)患者并发感染的危险因素,并通过两组治疗后伴发的感染情况,观察中成药(百令胶囊及六味地黄丸)对应用免疫抑制和糖皮质激素治疗的SLE患者的干预作用,从而探寻减少SLE伴发感染的治疗方案,寻找有效且相对安全的治疗方法。2.观察两组治疗前后的IL-2表达水平,推断调节免疫中成药减少SLE感染在细胞免疫方面的可能机制。方法1.分析SLE患者出现感染的危险因素：回顾研究我院和九江学院附属医院风湿科2009年1月1日-2012年1月1日收治的SLE患者82例,以性别、年龄、体质量、病程,血白细胞、血浆白蛋白水平,IL-2、C3、CRP数值,免疫抑制剂及激素应用情况为自变量,观察患者的感染发生率,以及感染发生率与这些指标之间的相关性。本研究中感染包括细菌感染、病毒感染、真菌感染；感染涉及呼吸系统、泌尿系统、皮肤和软组织、中枢神经系统及血液系统等。2.观察两组的临床疗效及两组感染情况：2.1研究对象：回顾性研究2009年1月1日～2012年1月1日伴有肾脏受累和或肺间质性病变的SLE患者61例(均来自规范治疗并定期复诊的患者,入选病例首诊时经常规检测并未合并感染)随机分成两组。中西医结合治疗组31例,男性4例,女性27例；年龄13-65岁,病程平均36.2月。西药对照组30例,其中男性2例,女性28例；年龄14-63岁,病程平均35.8月。两组患者在性别、年龄、病程、病情等方面经检验差异无统计学意义。2.2给药方法：对照组：对照组采用糖皮质激素加环磷酰胺进行治疗。A、糖皮质激素：泼尼松lmg/kg/d通常晨起1次服用,待患者病情稳定后2周或疗程8周内,以每2周减10%的速度缓慢减量,减至泼尼松0.5mg/kg/d,治疗的激素剂量尽量小至泼尼松10mg/d。在减药过程中,如果病情不稳定,可暂时维持原剂量不变。B、环磷酰胺：前半年每月一次,稳定后改为每三月一次(用量16-20mg/kg加入生理盐水250m1中静脉滴注,一般每天0.4-0.6g,连用两天)。对有病情严重者,可以使用较大剂量(泼尼松≥2mg/kg/d)甚至甲基泼尼松龙冲击治疗,甲基泼尼松龙可用至500～1000mg,每天1次,加入5%葡萄糖慢静脉滴注1～2小时,连续3天为1疗程,疗程间隔期5-30天,间隔期和冲击后需口服泼尼松1mg/kg/d-2mg/kg/d,疗程和间隔期长短视具体病情而定。治疗组：在对照组基础上加用六味地黄丸(8丸,每日三次)及百令胶囊(1.0g,每日三次)。2.3观察指标：通过SLEDAI评分观察病情；测定血常规、尿常规,ESR, CRP, C3、C4,IG,免疫荧光抗核抗体(ANA),抗ds-DNA抗体,肝肾功能等变化,比较两种疗法的治疗效果和伴发感染情况(肺部感染、泌尿系感染、中枢神经系统感染等)。两组疗程均为18个月,分别在治疗6、12、18个月后评估患者病情。3.百令胶囊联合六味地黄丸对SLE患者血清IL-2水平的影响分别在两组患者初诊及治疗后6、12、18个月后,常规分离患者外周血清3m1,并将其置于-80。C下保存备用。按照人IL-2ELISA检测试剂盒中所提供的检测操作说明,检测相应患者血清中IL-2水平。结果1.结果显示SLE患者伴发感染的易感因素主要有补体缺陷(补体C3),糖皮质激素冲击、长期免疫抑制剂使用,病情活动性,累及系统和脏器的数量,住院时间相关(P<0.05)；与性别、年龄、体质量、病程无明显相关(P>0.05)；SLE合并感染以呼吸道部感染和泌尿系感染为主；病原菌以革兰阴性菌为主,条件致病菌相对较多。2.临床研究得出：治疗组总有效率(83.8%)高于对照组(73.3%),其差异有统计学意义。治疗6个月后治疗组感染率9.67%,对照组16.67%；治疗12个月后治疗组感染率12.90%；对照组20.68%；18个月后感染率,治疗组16.67%,对照组为25%,治疗组感染率明显低于对照组,经统计学分析有显著差异(P<0.05)。3.治疗组患者IL-2水平显著高于对照组,治疗6个月、12个月、18个月后,治疗组白介素2水平分别为6.97±1.32pg/ml,7.26±1.25pg/ml；7.54±1.24pg/ml;对照组为5.29±1.26pg/ml；5.42±0.99pg/ml；5.63±1.15pg/ml.经统计学分析两组数据有差异(P<0.05)。结论1.对照组(单纯免疫抑制治疗系统性红斑狼疮组),患者易伴发感染,这也是导致患者多脏器功能衰竭甚至死亡的重要原因。长期大剂量免疫抑制剂、激素冲击治疗,免疫力低下(血白细胞计数降低、血浆白蛋白水平下降等),C3水平低下、累及的脏器个数,住院时间延长、病情活动性是伴发感染的独立危险因素。2.百令胶囊联合六味地黄丸可以有效缓解免疫抑制剂和激素治疗系统性红斑狼疮导致的并发症,增加临床疗效,可以减少SLE患者出现感染的几率,减轻感染症状。故可以作为临床医师治疗系统性红斑狼疮的一种有效治疗方案。3.百令胶囊联合六味地黄丸增加了系统性红斑狼疮患者IL-2的分泌；能减少系统性红斑狼疮并发感染率,可能与增高的IL-2可促进患者本病的病情稳定有关。从侧面说明二者有通过调节免疫作用达到改善肺部、肾脏等脏器的功能状态,提高患者免疫力的作用。意义1.本研究主要观察了调节免疫中成药对系统性红斑狼疮患者免疫抑制治疗后并发感染率的影响。目前国内外很少见到相同的研究报告,研究内容新颖,临床实用性强；拓宽了研究视野,为以后深入研究打下了一定基础。2.本研究检测了系统性红斑狼疮患者的IL-2水平,发现实验组的IL-2水平的增高与该组的感染率下降相平行,从而为通过细胞因子网络调控领域探讨调节免疫中成药作用机理提供了基础；为该类药治疗效果的评判提供了一个有参考价值的范例。更多还原

【Abstract】 BackgroundSystemic lupus erythematosus(SLE) is an autoimmune disease. It is a kind of diffuse connective tissue disease characterized by producing a variety of antibodies and immune response mediated inflammation. It related to involvement of several visceral organs. The condition ranges from mild to severe. In recent20years, the cyclophosphamide (CTX) and corticosteroid therapy were used as a classic method for the induction therapy of heavy SLE internationally. Lupus crisis often need combined with CTX, the impact of large dose methylprednisolone and immune globulin or three treatment. At present, there are many new advances in the treatment of SLE. However, the treatment is still dominated by hormone and immunosuppressant at home and abroad. They can effectively control the disease activity, improve the condition and the survival rate of patients with SLE. But the side effects of high dose immunosuppression and hormone can not be ignored. Many clinical studies showed that more than20%of the patients with high dose CTX, methylprednisolone treatment can occur the symptoms of infection, such as herpes zoster, pneumonia, urinary system infection and meningitis. Especially, the probability of complications in the immunocompromised patients after treating with pulse therapy increased greatly.The infection has become one of the main causes of death in patients with SLE.In recent years, the role of Chinese medicine in the treatment of SLE has caused some medical attention, In the ancient literature of traditional Chinese medicine, although there is not the same discussion named systemic lupus erythematosus disease, the similar or related is discussed extensively. After thousands of years of accumulation, the paper discusses involved the different aspects about SLE. According to its clinical symptoms, many Chinese scholars will it belongs to "HuDieBan","Yin and Yang poison","Sun boils" category. In the current domestic physician of TCM have knowledge about SLE, most believe that the foundation of this disease is inadequate natural endowment. So filling its deficiency account for important position in the study of SLE. Representative drugs such as Liuwei dihuangwan, Bailing capsule and so on.Liuwei dihuangwan is Yin and Yang on behalf of the party with Ziyin kidney function. The prescription Composed of Radix rehmanniae, Cortex Moutan, Oriental waterplantain rhizome, dogwood, yam, Poria six taste medicine.In the prescription Radix rehmanniae is on nourishing kidney essence role mainly, with dogwood nourishing liver and kidney and astringing essence, with Yam tonifying spleen and kidney and solid essence. Poria cocos light infiltration spleen wet to help Yam tonifying spleen. Poria cocos ooze water wet, making water the downward and out of body. Alisma discharge kidney fire and prevent the Rehmannia greasy. Cortex Moutan cleare liver fire, cool blood stasis, in addition to the bone steaming hot and wet of dogwo. The curative Effect of this prescription is exact after hundreds of years for medical use. This prescription is aigorous and become the representative prescription of nourishing kidney yin. Modern pharmacological studies confirmed: Rehmannia glutinosa have excited or adjusted adrenocortical axis function.lt can antagonize the inhibition of exogenous hormone on pituitary adrenal, delay liver decomposition of cortical hormone, and prompte the cortical hormone of the blood elevated. It can keep the physiological effects of glucocorticoid and reduce the side effects of glucocorticoid induced also.Bailing capsule consists of Artificial Cordyceps mycelium.It is consistent with natural Cordyceps sinensis, and has nourishing the lung and kidney, Yijing gas effect. Recent studies suggest that caterpillar fungus has antioxidant effect, improve organism cellular immunity, and reduce the side effects caused by glucocorticoid in protein decomposition and infections. It has the function of bidirectional regulation of human immune cells, can reduce the immunosuppressive drug side effects,but also have synergistic effect with immunosuppressive drugs. Cordyceps has good anti-inflammatory and immunomodulating effects, no hormone kind of side effects. The research reports about the Bailing Capsule Combined with Liuwei dihuangwan reducing the side effects caused by glucocorticoid and immune agents in SLE patients are few, especially on the intervention study of SLE complicated with infection. In the clinical practice of the past few years, we have been trying to give Liuwei dihuangwan combined with Bailing Capsule in treating SLE patients. Results showed that, increasing the above treatment can effectively reduce the risk of infection and can reduce the degree of infection in SLE patients; but also improve the clinical efficacy, reduce the mortality rate. Therefore, we did this research.Objective1. to learn about the risk factors of systemic lupus erythematosus (SLE) patients complicated with infection and the infections in two groups after the treatment, observating the intervention effect about regulation of immune medicine (bailing capsule and Liuwei Dihuangwan) on the SLE patients with immunosuppression and hormone therapy. So as to explore the therapeutic regimen of reducing SLE infection, looking for the effective and relatively safe ways for the treatment of SLE.2. to observate the expression levels of IL-2in two groups before and after treatment, concluding the possible mechanism of immune medicine reducing SLE infection in cellular immune.Methods1. Analysis of SLE patients with risk factors for infectionRetrospective study of82cases of patients with SLE on our hospital from January1,2010to December31,2012. The variables include gender, age, body mass, disease course, white blood cell, HGB, plasma albumin level, value IL2, C3, CRP, immune inhibitors and hormone application. To observe the incidence of infection and the correlation between the incidence of infection with these variables. In this study, the infection include bacterial infection, viral infections, fungal infection, involving the respiratory system, urinary system, skin and soft tissue, the central nervous system and blood system,etc.2. To observe the clinical curative effect and infection of two groups.2.1Retrospective study from the January1,2010to December31st,2012was associated with61cases of SLE patients with renal involvement and or interstitial lung disease (from the standard hospital treatment and regular follow-up of patients, selected cases that do not merge infection at first diagnosed). According to the severity of the disease were randomly divided into two groups. There were31cases in the Chinese and Western medicine treatment group, including4males,27females, age13to65years old, and average duration is36.2months. The western medicine control group contain30patients, including2males,28females, age14to63year old, and average duration is35.8months.2.2Method of administrationThe western medicine control group:The western medicine control group are given with glucocorticoid and cyclophosphamide therapy. A、glucocorticoid: prednisone(lmg/kg/d) is usually one-time taking in the morning, after two weeks in stable disease or eight weeks, then began to slow reduction at the rate of10%every two weeks until the prednisone0.5mg/kg/d, and treatment of hormone doses as far as possible little to10mg/d. In the reduction of drug in the process, if the condition is not stable, can temporarily maintain the original dose. B、 cyclophosphamide:once a month in the first half of the year after stability to every march(the dosage of16-20mg/kg added into250ml physiological saline for intravenous drip, generalty erery day0.4-0.6g, stay for two days). To the serious cases,we can use large dose (prednisone≥2mg/kg/d) and methylprednisolone pulse therapy. MP available to500-1000mg, one times a day, adding5%glucose slow intravenous drip for one to two hours, for three consecutive days to one course of treatment, treatment interval between five to thirty days. Oral prednisone (lmg/kg/d-2mg/kg/d) are used during interval or after pulse therapy. The course of treatment and interval length depend on the specific disease.The Chinese and Western medicine treatment group:on the basis of the western medicine plus Liuwei Dihuagnwan(8pills, three times a day) and Bailing Capsule(1.0g, three times a day).2.3Observation index:Through the observation of ESR, CRP, C3, C4, IG, ANA, ds-DNA, SLEDAI score, blood routine test, liver and kidney function, to compare curative effect of two kinds of therapy and the infection (pulmonary infection, urinary tract infection, infection of the central nervous system,etc.). Two groups both were treated for18months, and assessed at6,12,18months after the treatment.3. Effect of Bailing Capsule Combined with Liuwei Dihuagnwan on serum IL-2level in patients with SLE.Respectively in the two groups of patients at the first diagnosis and treatment of6,12,18months later, the conventional separation of peripheral serum3ml, then save it in the spare-80°C. According to the test operation provided by IL-2kit instructions, testing the patients’ serum level of IL-2.Results1. The study found that the risk factors of SLE patients with infections include defect of complement (Complement C3), immune abnormalities (Blood leukocyte count、Plasma albumin levels),disease activity, hormone impact, long-term immunosuppressive therapy, number of the affected organs, duration of hospitalization. They have significant difference by statistics analysis(P<0.05). Infection had no correlation with sex, age, body mass, and disease duration (P>0.05). The active parts of SLE with infection mainly concentrated in the respiratory tract and urinary tract. The pathogenic bacteria were mainly gram-negative bacteria. Conditional pathogenic bacteria is relatively more. 2. The total effective rate of treatment group (83.8%) was higher than that of the control group (73.3%), the difference was statistically significant. After6treatment months in treatment group the infection rate was9.67%, control group16.67%.After12treatment months, the infection rate was12.9%, control group20.8%;18months later, the infection rate was16.67%in treatment group, control group25.00%. The infection rate of treatment group was significantly lower than the control group(P<0.05).3. The level of IL-2of the treatment group was significantly higher than the control group.6months,12months,18months later, interleukin2levels of treatment group respectively were6.97±1.32pg/ml,7.26±1.25pg/ml,7.54±1.24pg/ml. Interleukin2levels of control group respectively was5.29±1.26, pg/ml,5.42±0.99pg/ml,5.63±1.15pg/ml. There was statistical significance between the two groups (P<0.05). The levels of IL-2before treatment was5.39±1.06pg/ml in the control group, the treatment group5.41±1.03pg/ml.Conclusion1.The immunosuppressive therapy in patients with systemic lupus erythematosus is easy to cause infection, it is also an important cause of patients with multiple organ failure and even death. Long term high dose immunosuppression, corticosteroid therapy, low immunity(low blood leukocyte count,Plasma albumin levels drop), low levels of C3、number of the affected organs, duration of hospitalization, the activity of disease were independent risk factors of infection.2. Bailing Capsule combined with Liuwei Dihuangwan can effectively alleviate the complication that caused by immune inhibitor and hormone in the treatment of systemic lupus erythematosus, and increase clinical therapeutic effect. Besides, it can reduce the risk and the symptoms of infection. Therefore, they aer an effective therapeutic regimen for clinicians in the treatment of systemic lupus erythematosus.3. Bailing Capsule combined with Liuwei Dihuagnwancan increased the secretion of IL-2in patients with systemic lupus erythematosus. This treatment can reduce the infection rate in the systemic lupus erythematosus, it may be associated with increased IL-2that can promote the patients in stable disease. This means they can adjust immune function to improve the lungs, kidneys and other organs function from the side, and can improve the immunity function.Significance1.Technique route of this research is practical and clear. This research mainly observed the effect about the regulation of immune medicine on immunosuppressive therapy in patients with systemic lupus erythematosus complicated with infection. At present the same study rarely seen at home and abroad. The research content is novel and clinical practicability is very strong. This study broaden the research perspective and lay a certain foundation for further research.2.This study examined the level of IL-2in the patients with systemic lupus erythematosus, and found that the increased IL-2of the treatment group is contacted with the reduce of infection in this group. The report provides the basis to investigate the mechanism of regulation of immune medicine through cytokine network. In addition, it also provides a valuable paradigm for evaluation about this kind of drug on the therapeutic effects.更多还原